The pathophysiology of heart failure (HF) with kidney dysfunction is represented by several maladaptive bidirectional pathways wherein acute or chronic dysfunction of one organ drives acute or chronic dysfunction in the other organ. Suboptimal decongestion, diuretic resistance, and low use rates of guideline-directed medical therapy in individuals with kidney dysfunction and HF contribute to poor cardiovascular and kidney outcomes. Recent developments with the early identification and treatment of diuretic resistance may help mitigate the harmful effects of persistent congestion in individuals with HF.