Background The decision for a simultaneous liver and kidney transplantation (SLKT) is fraught with controversy. The aim of this study was to compare SLKT with liver transplantation alone (LTA) in patients with pretransplantation renal failure. Study Design A retrospective review comparing patients undergoing SLKT and LTA (with renal failure) between January 2000 and December 2014 was performed. Results Of 1,129 liver transplantations, 132 had renal failure pretransplantation; 52 had SLKT and 80 recipients had LTA. Model for End-Stage Liver Disease score and BMI were lower in the SLKT group (p = 0.001). Simultaneous liver and kidney transplantation patients had better overall survival rates at 1 and 5 years compared with LTA (92.3% and 81.6% vs 73.3% and 64.3% respectively; p < 0.01). Graft survival was also superior in patients undergoing SLKT vs LTA. Six of 52 (11.5%) SLKT patients had final positive cross match, but only 1 of 52 (1.9%) kidney grafts was lost to rejection. In the SLKT group, 9 of 52 (17.3%) patients required dialysis post transplantation, but only 2 remained on dialysis beyond 30 days. All patients in the LTA group were on dialysis pretransplantation and significantly more patients (52 of 80 [65%]) required dialysis post LTA (p ≤ 0.0001); 31 of 80 (38.8%) were dialysis dependent for more than 30 days or died on dialysis within 30 days. Two LTA recipients were subsequently listed for kidney transplant. Conclusions Patients with end-stage liver disease on dialysis who undergo liver transplantation have significantly better survival when SLKT is performed. In selected patients, SLKT is an appropriate use of a scarce resource, but better prognostic indicators for selection of patients are still needed.