Severe renal insufficiency is considered a relative contraindication to left ventricular assist device (LVAD) implantation. After establishing an algorithmic approach to these patients, we hypothesized that LVAD implantation with severe renal insufficiency could be performed without increasing morbidity or mortality. All consecutive patients (July 2015-December 2017) who underwent LVAD implantation were retrospectively reviewed. Patients were stratified by preoperative glomerular filtration rate (GFR): ≤30 mL/min/1.73 m2 (low-GFR) and >30 mL/min/1.73 m2 (high-GFR). Preoperative optimization included aggressive inotropic support and temporary mechanical circulatory support before LVAD implantation in any patient with an acute component of renal insufficiency. All patients with a preoperative GFR ≤15 mL/min/1.73 m2 were prophylactically initiated on temporary renal replacement therapy postoperatively. The primary outcome was Kaplan-Meier 1-year survival. Fifty-eight patients (21 with low-GFR and 37 with high-GFR) were identified. Patients in the low-GFR cohort had a significantly higher median Interagency Registry for Mechanically Assisted Circulatory Support score and worse preoperative end-organ function. Preoperative optimization resulted in an increase in GFR to >30 mL/min/1.73 m2 in 11 out of 21 patients from the low-GFR cohort. Inotrope days, ventilator time, intensive care unit length of stay, and hospital length of stay were not significantly different between the groups. Kaplan-Meier 1-year survival was 81% in the low-GFR cohort and 86% in the high-GFR cohort (P = .98). Subset analysis of GFR ≤15 mL/min/1.73 m2 (n = 11) and ≥60 mL/min/1.73 m2 (n = 19) demonstrated identical 1-year survival (89% vs 89%; P = .91). LVAD implantation in carefully selected patients with severe renal insufficiency can be performed without increasing midterm morbidity or mortality. This strategy may serve as a successful option to bridge patients to transplantation or destination therapy. Copyright © 2019. Published by Elsevier Inc.