Abstract Background and Aims Kidney biopsy is the gold standard test for assessing kidney disease and offers pivotal insights into the diagnosis, prognosis, and treatment of kidney disorders. However, its application in patients with a diminished glomerular filtration rate (GFR) poses a heightened risk of complications. In this study, we explored the safety and utility of kidney biopsy in patients with an estimated GFR <15 ml/min/1.73 m2. Method In this prospective study, we enrolled consecutive adult patients with an eGFR below 15 ml/min/1.73 m2 who underwent a kidney biopsy and provided informed consent. Exclusions comprised patients with solitary or transplanted kidneys or acute kidney injury. All biopsies were performed under ultrasound guidance. Following the procedure, patients were observed for 24 hours to monitor complications, and an analysis of their associated risk factors was done. Results Among the 88 patients included in the study, 60% were male, 20% had diabetes, and 30% were hypertensive. Chronic glomerulonephritis (45%), with IGA nephropathy being the most prevalent), chronic tubulointerstitial disease (43%), and diabetic kidney disease (12%) were the predominant histological diagnoses in kidney biopsies. Peri-renal hematomas ≥2 cm were observed in 9 patients, with three requiring blood transfusions. A major complication necessitating angioembolization occurred in one patient. The biopsy sample was deemed adequate in 80% of patients (n = 70). The requirement of blood transfusion (p < 0.04) and hemodialysis before biopsy (p = 0.05) was associated with an increased risk of complications. This study suggests the safety and necessity of kidney biopsy in CKD patients, underscoring its importance for accurate diagnosis and the initiation of appropriate therapeutic measures, irrespective of GFR Conclusion This study suggests the safety and necessity of kidney biopsy in CKD patients, underscoring its importance for accurate diagnosis and the initiation of appropriate therapeutic measures, irrespective of GFR