Aim and background: Chronic kidney disease (CKD) patients on hemodialysis with ejection fraction (EF) <30% are reported to have a nine times higher risk of mortality rate than those with EF >60%. Patients with diastolic dysfunction also have an increased incidence of cardiac events. Kidney transplant provides better quality of life and prevents further deterioration of cardiac function as compared to dialysis. The intraoperative period is challenging in these patients as adequate renal perfusion has to be delivered to achieve good urine output while sustaining cardiac parameters within the optimal range. Case description: A 35-year-old male was posted for a live donor renal transplant. The two-dimensional (2D) echocardiography reported global hypokinesia of the left ventricle with severe left ventricular (LV) dysfunction. The EF was 25–30%. Diastolic dysfunction grade III with E/A 1.36, E/E 24.02, and DT 82 ms. Intraoperatively increased blood pressure was managed with nitroglycerine infusion, which was titrated to 0.4 mg/hour. The patient was hemodynamically stable throughout the procedure. The fluid infusion was guided by central venous pressure (CVP), which was maintained at 10–12 mm Hg at the time of declamping. The transplanted kidney functioned well immediately. Conclusion: Preoperative optimization of cardiac status, invasive monitoring for various cardiac parameters, carefully tailored anesthesia, and intense postoperative care are essential for successful transplants in such cases. Providing adequate renal perfusion while maintaining various cardiac parameters in optimal range is challenging but crucial. Clinical significance: Various studies have reported posttransplant normalization of lower EF due to uremic cardiomyopathy in the absence of cardiac ischemia. Increased incidence of major adverse cardiovascular events (MACE) has been reported in surgical patients having diastolic dysfunction; hence increased vigilance is required. Renal transplants can be carried out in patients with these parameters.