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KEY POINTS: Finerenone reduced albuminuria versus placebo in patients with a history of nephrectomy, similar to those without a history of nephrectomy. Incidences of treatment-emergent adverse events or serious adverse events were generally similar in patients with and without history of nephrectomy. Finerenone may delay kidney disease progression in patients with CKD and type 2 diabetes, irrespective of nephrectomy status. BACKGROUND: Finerenone significantly reduced the risk of cardiovascular and kidney outcomes in patients with CKD and type 2 diabetes (T2D) in FIDELITY, a prespecified pooled analysis of two phase 3 trials. This post hoc FIDELITY analysis examined the efficacy and safety of finerenone in patients with CKD, T2D, and a history of nephrectomy. METHODS: Patients in FIDELITY were randomized to receive finerenone or placebo and were on optimized renin-angiotensin system inhibition. We identified nephrectomy status using patients' medical history and assessed CKD progression in patients by nephrectomy status at baseline by modeling change in urine albumin-to-creatinine ratio from baseline to months 4-24. Safety outcomes included treatment-emergent adverse events and incident hyperkalemia. RESULTS: Of 12,990 patients, 108 had a history of nephrectomy at baseline; 101 of 108 had radical nephrectomy, 55 received finerenone, and 53 received placebo. Baseline mean eGFR were numerically lower in patients with a history of nephrectomy (48±17 ml/min per 1.73 m 2 ) than in patients without (58±22 ml/min per 1.73 m 2 ). For patients with a history of nephrectomy, those who received finerenone had a greater urine albumin-to-creatinine ratio reduction at 4 months versus those who received placebo (least-squares mean ratio to baseline, 0.65 versus 1.09; least-squares mean treatment ratio, 0.60; 95% confidence interval, 0.48 to 0.76; P < 0.001). This reduction was maintained for 2 years. Treatment-emergent adverse events were similar in patients with and without a history of nephrectomy. Among patients with a history of nephrectomy, treatment-emergent hyperkalemia occurred in 7% and 6% of finerenone and placebo groups, respectively. CONCLUSIONS: Finerenone reduced albuminuria compared with placebo and demonstrated a safety profile consistent with the overall FIDELITY population in patients with and without a history of nephrectomy at baseline. Finerenone may delay CKD progression and associated morbidity in patients with CKD and T2D, irrespective of nephrectomy status. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: FIDELIO-DKD ( NCT02540993 ); FIGARO-DKD ( NCT02545049 ).