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Figure. Treatment algorithm for patients with systolic heart failure, based on renal function. Renal function should be categorized by estimated glomerular filtration rate (GFR), which can be calculated from the serum creatinine level. Evidence supporting a beneficial effect on clinical outcomes from each medication within subgroups of renal function is evaluated as definite, possible, or unknown by the author. These definitions are based on the range of renal function represented within the clinical trials and the reporting of results specific to patients with renal insufficiency. ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker. *Using Cockcroft–Gault equation (6) or Modification of Diet in Renal Disease formula (7).  Careful monitoring of renal function and electrolytes.  Possibly harmful because of hyperkalemia risk.  Consider withholding therapy during states of volume depletion because of hyperkalemia risk. ||Shown to help reduce hospitalization but not mortality.
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