Implantation of implantable cardioverter defibrillators (ICDs) for primary prevention has been shown to significantly reduce mortality in several randomized controlled trials. However, many of these trials have excluded patients on hemodialysis as well as patients with advanced chronic kidney disease (CKD). Whether the benefits of ICD therapy extend to patients with CKD is not clear. This review will examine the relationship between advancing stage of CKD and risk/benefit of ICD placement. Furthermore, we will review the recent evidence for the rates of complications as CKD advances. The intent is to assist the clinician who is considering the risks and benefits of ICD implantation in patients who have significant competing comorbidities and have not been specifically studied in randomized controlled trials.