<i>Background:</i> Patients with heart failure (HF) and kidney disease have a poor long-term outlook which has provided impetus for the identification of factors of prognostic importance and more fully understanding the impact of kidney dysfunction in patients with HF. <i>Objectives:</i> Our objectiveswere to describe the characteristics, hospital treatment practices, as well as hospital and long-term outcomes in patients with varying degrees of kidney dysfunction who were hospitalized with acute HF at all medical centers in a large New England metropolitan area. <i>Methods:</i> Residents of the Worcester metropolitan area hospitalized with clinical findings of decompensated HF at 11 greater Worcester medical centers during 1995 and 2000 comprised the study sample. Kidney function was classified into 4 categories of estimated glomerular filtration rate (eGFR) for purposes of analysis: <30 (n = 569), 30–44 (n = 725), 45–59 (n = 763), and ≧60 (n = 2,293) ml/min per 1.73 m<sup>2</sup>. <i>Results:</i> The average age of the study sample was 76 years and 57% were women. Patients with severe kidney dysfunction were less likely to receive angiotensin-converting enzyme inhibitors, diuretics and digoxin during hospitalization for acute HF compared to patients with more normal kidney function. Patients with lower eGFR levels had higher in-hospital and post-discharge death rates in comparison to those with higher levels of eGFR. <i>Conclusion:</i> Our results demonstrate the impact of renal impairment on the prognosis of patients with decompensated HF. Our findings highlight the less than optimal management of these high-risk patients. Increased surveillance and enhanced treatment of patients with HF and kidney dysfunction remains warranted to improve the survival outlook of these patients.