People with severe CKD (eGFR<30 ml/min/1.73 m2 ) have largely been excluded from key randomised controlled trials of heart failure pharmacotherapies, and the evidence base for such therapies in this important subgroup has therefore been lacking and clinical practice inconsistent The presence of even mild or moderate CKD (eGFR 31-59 ml/min/1.73 m2 ) can limit the ability to introduce and/or adequately up-titrate heart failure medications, many of which are potentially nephrotoxic and often reduced or discontinued in people with worsening renal function or acute kidney injury complicating intercurrent illness or concomitant drug therapy. People with CKD are also more prone to develop adverse effects related to their heart failure medication including hyperkalaemia and hypotension as well as worsening renal function, which is often mild but may be significant in the long term and contribute to deteriorating renal function and worsening heart failure prognosis As a result, there may be significant underutilisation of evidence-based pharmacotherapies in people with heart failure who also have CKD, particularly those with HFREF, who may be denied potentially life-saving disease-modifying medication. When considering the update of this guideline this topic was highlighted as an important area to review to establish if pharmacological interventions recommended for the general heart failure population were associated with similar clinical benefits, risks and cost effectiveness in people with heart failure who also have CKD. 6.2.6.2 Review question: What is the clinical and cost effectiveness of pharmacological interventions for heart failure in people with heart failure who also have chronic kidney disease? For full details see review protocol in Appendix A. Table 58: PICO characteristics of review question Population Adults with heart failure and chronic kidney disease (at least stage 3A / eGFR <60 mL/min), who are not on dialysis. 