Heart transplantation is the only potential “cure” for a patient with advanced CHF and kidney dysfunction that is thought to be reversible. Differentiating between prerenal state versus renal parenchymal damage is important when considering heart transplantation alone versus combined heart-kidney transplantation. Unfortunately, based on a recent series of heart transplant candidates, simple laboratory tests at the time of heart transplant evaluation, such as measurement of urine protein excretion and estimated glomerular filtration rate, do not correlate with the degree of fibrosis on renal biopsy. Therefore, in patients with advanced CHF who require transplantation, a renal biopsy may be a crucial step in the preoperative assessment.