Renal and hepatic function are often intertwined both through the existence of associated primary organ diseases and hemodynamic interrelationships. This connection occasionally results in the chronic failure of both organs, necessitating the need for combined kidney-liver transplantation. Since 1990, over 1,790 patients in the United States have received such transplants with a patient survival somewhat less than that for patients receiving either organ alone. Patients with renal failure due to acute injury or to the hepatorenal syndrome have classically not been included as candidates for combined transplantation due to the reversibility of the renal dysfunction following liver transplantation. However, the rate and duration of renal failure prior to liver transplantation continues to be prolonged even with the new allocation scheme prioritizing liver transplants to those with renal failure. Thus the issue of when kidney transplantation should be offered and what evaluation is necessary prior to the decision continues to confront the transplant community.