Renal dysfunction is seen very often in patients with liver disease, either secondary to the impact of liver failure or as a direct impact of metabolic syndrome on both organs as it is now the commonest etiology for both liver (MASLD) and renal failure. It is important to identify the etiology of the renal dysfunction, categorize the severity of liver and renal disease, and understand the reversibility of renal dysfunction to decide on the management plan. The fallacy lies in the available markers of renal dysfunction in liver disease; they do not provide a correct assessment of the current condition of renal dysfunction. Guidelines for combined liver and kidney transplant have been developed taking into account this caveat. Once a decision is made to do a dual organ transplant (liver and kidney), the discussion should focus on the timing and sequence of the dual organ transplant, the donor options, and management of the pre- and postoperative periods. This chapter takes a stepwise approach to the assessment and management of patients requiring combined liver and kidney transplantation.