The committee stressed that close monitoring is even more important in patients with CKD to help prevent hyperkalaemia and possible acute kidney injuries, and therefore the cost of monitoring could be offset by the savings by reducing the potential adverse effects of heart failure treatment on kidney function. The committee stated that close monitoring of patients with HFREF and CKD is common in current practice as these patients are high risk and therefore did not consider that there would be a significant additional resource impact. Based on the balance of the clinical risks and benefits the committee considered that as these drugs are highly cost effective for HF-REF patients and the additional cost of monitoring would be low that these treatments would remain cost effective in patients with HFREF and CKD stages I to IIIb. Other considerations Most patients with heart failure will have some degree of renal impairment. Specialist renal care for people with co-morbid CKD and heart failure is unusual, as renal physicians generally take referrals only after stage IV, unless there are other kidney issues. The committee reported a lack of clarity about using ACE-I, ARB and MRA in patients with CKD where renal function is declining. They discussed that in these circumstances, total cessation of these medications may deprive patients of the beneficial effects on morbidity and mortality. Therefore, modification to the doses of these agents, or even temporary cessation of one or more agents, should be made based on individual patient circumstances, and guidance from renal physicians should be considered where necessary. Due to the lack of evidence identified in this review for those with more severe CKD the committee noted this as an area warranting further research attention. 