Patients with end-stage liver disease often present with hepatorenal syndrome (HRS). Prior to the introduction of liver transplant this was a fatal complication. However, these patients can now undergo successful liver transplantation. HRS, however, leads to increased mortality on the waiting list, difficult intraoperative and postoperative challenges and decreased survival compared to non-HRS patients. These include renal replacement support, fluid and electrolyte shifts, and postoperative immunosuppression. HRS patients have longer ICU stays, hospital length of stay, decreased long-term renal function and a higher incidence of end-stage renal disease following liver transplantation. Despite this, the 5-year survival can exceed 65%. There has been a recent trend in increasing liver kidney transplantation. Efforts are underway to develop criteria for patients who would benefit from combined liver kidney transplantation, and these are reviewed. Recent research has indicated that reversing HRS preoperatively may improve long-term survival postoperatively and this area of research needs to be expanded.