Renal dysfunction is a challenge frequently encountered while treating patients with advanced heart failure. Chronic kidney disease and acute kidney injury are well-established risk factors for adverse outcomes after implantation of durable mechanical circulatory support devices. In this chapter, we comprehensively review the mechanisms of renal injury in advanced heart failure patients, its impact on outcomes after left ventricular assist device implantation, as well as recommendations for reno-protection in the peri-implantation period. We also explore the clinical implications of renal dysfunction in patients undergoing total artificial heart implantation.