In patients with preserved renal func- tion or mild to moderate renal impairment, renal function and potassium after initiation and titration of aldosterone antagonists should be assessed within 2 to 3 days and again at 7 days. The schedule for subsequent monitoring should be dictated by the clinical stability of renal func- tion and volume status but should occur at least monthly for the rst 3 months and every 3 months thereafter (3). During the initiation and titration of agents that affect renal function, a decrease in eGFR of >30% or the development of hyperkalemia should alert the clinician that a reduction in doses may be necessary, even though short-term changes in eGFR during intense diuretic therapy or with the initiation of an ACEI or ARB do not predict longer-term adverse outcomes (48), and initial mild worsening of renal function after SGLT2 inhibitor initiation may also occur before longer-term renal func- tion preservation (13). In patients with evidence of hypovolemia, the dose of diuretic agents should be reduced. The ARNI dose may also need to be reduced in the setting of renal insuf ciency or hypotension. Hyper- kalemia may also require changes in medical therapy. Among SGLT2 inhibitors for patients with chronic HFrEF, clinical trial experience with dapagli ozin is lacking in , whereas for empagli ozin, there is a similar lack of clinical trial data for those with an eGFR <20 mL/min/1.73 m2 . Volume status should be closely monitored, as intravascular vol- ume contraction may necessitate a reduction in loop diuretic dosing. Clinical assessment and renal stability in each patient dictates whether clinicians may need to monitor certain patients more closely than others. Socioeconomic barriers to care may undermine the ability to achieve GDMT. 