Background: Since early reports of combined thoracic–renal transplantation in the late 1970s, dual-organ heart–kidney and lung–kidney transplantation has emerged as a strategy to address irreversible chronic kidney disease (CKD) in thoracic transplant candidates, where calcineurin-inhibitor nephrotoxicity and pre-existing renal dysfunction confer excess mortality and dialysis dependence. Early series demonstrated technical feasibility and suggested lower rejection rates with same-donor concurrent transplantation. Methods: We reviewed contemporary international literature on combined heart–kidney and lung–kidney transplantation, focusing on survival, graft outcomes, and post-transplant dialysis. We also describe the Alfred Health experience (the major heart/lung transplant service in Australia) using Australasian Vascular Audit data from 2010-2025 with 292 renal transplants, including 3 heart–kidney and 3 lung–kidney procedures. Results: Registry and single-centre studies show that simultaneous heart–kidney transplantation improves survival compared with isolated heart transplantation in patients on dialysis or with pre-transplant GFR<40, with 5-year survival of ~70–75% and reduced cardiac rejection and allograft vasculopathy. Lung–kidney transplantation is associated with improved 1–3-year survival and lower dialysis dependence versus isolated lung transplantation in recipients with eGFR<30 or pre-transplant dialysis, though kidney allograft loss is higher than in isolated kidney recipients. Evidence supports considering prophylactic renal transplantation at mGFR<40–50 in selected patients, balancing operative efficiency and renal benefit against graft attrition and allocation ethics. Conclusions: Dual thoracic–renal transplantation offers meaningful survival, immunologic, and renal benefits in patients with advanced cardiorespiratory failure and CKD. Emerging data support prophylactic kidney transplantation in those with mGFR<50 at highest risk of post-transplant renal failure.