Worsening renal function (WRF) during the treatment of acute decompensated heart failure (ADHF) occurs in up to a third of patients and is associated with worse survival. Venous congestion is increasingly being recognized as a key player associated with WRF in ADHF. Understanding the hemodynamic effects of venous congestion and the interplay between venous congestion and other pathophysiological factors such as raised abdominal pressure, endothelial cell activation, anemia/ iron deficiency, sympathetic overactivity, and stimulation of the renin-angiotensin-aldosterone system will help in devising effective management strategies. Early recognition of venous congestion through novel techniques such as bioimpedance measurements and remote monitoring of volume status combined with customized diuretic regimens may prevent venous congestion and perhaps avoid significant WRF.