Although some bene t has been found for dual therapy in HF, this has not been con rmed so far in patients with CKD with or without diabetes. The Work Group believes that patients and providers would want to avoid hyperkalemia and AKI because of the associated downstream risks as well as the need for more frequent laboratory tests, of ce and emergency department visits, additional short-term therapies, and adjustment in diet. Resource use and costs. Resource utilization and costs in- crease, instead of decrease, by instituting dual RASi therapy compared to monotherapy. Considerations for implementation. Given that dual RASi therapy decreases proteinuria, practitioners might be tempted to institute dual therapy to treat very high levels of albuminuria in selected patients, even recognizing the risks of hyperkalemia There is, unfortunately, no RCT data on safety or kidney ef cacy of dual therapy in patients with very elevated There is a report that dedicated clinics for remission of progression of kidney disease are superior to There is insuf cient information to differentiate between men and women for this recommenda- tion, and there remains insuf cient evidence that there are different outcomes by race or age. In summary, dual therapy should be discouraged for patients with CKD with or without diabetes, with or without albuminuria. Rationale The belief that dual therapies of RASi are bene cial, compared to monotherapies, stemmed only from the improvement in albuminuria with dual therapy. Addition of an MRA to ACEi or ARB. Limited data have shown that the addition of an MRA, such as spironolactone, epler- enone, or nerenone, to an ACEi or ARB for renoprotection in patients with diabetes and kidney disease resulted in a reduc- tion of albuminuria but a higher risk of hyperkalemia. 