We appreciate the comments by Eschalier et al about our recent report. Findings from multiple large multicenter randomized control trials have established the efficacy of mineralocorticoid receptor antagonists in heart failure and reduced ejection fraction (HFrEF). However, these data come from randomized control trial-eligible patients with relatively normal kidney function. A recent propensity score study in real-world eligible patients with HFrEF suggested that unlike other evidence-based heart failure therapies such as with angiotensin-converting enzyme inhibitors and β blockers, there might be gaps between clinical efficacy and clinical effectiveness of mineralocorticoid receptor antagonists. In our study, we demonstrated a potential harm from spironolactone use in real-world patients with HFrEF with advanced kidney disease, who were excluded from randomized control trials and guidelines recommendations. Thus, we believe that findings from our study provide timely evidence that support the guideline recommendation against the use of these drugs in patients with HFrEF and advanced kidney disease and are expected to help improve care and outcomes of these patients.
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