Cardiac disease is the major cause of death in dialysis patients, accounting for 45% of all-cause mortality. Sudden cardiac death may be implicated in 60% of these cardiac deaths in dialysis patients. The combination of obstructive coronary artery disease, electrolyte shifts (in hemodialysis patients), left ventricular hypertrophy, and abnormal myocardial ultrastructure and function may contribute to the vulnerability of ESRD patients to sudden death. In this review, the epidemiology of cardiac arrest in dialysis patients is presented, including the high lethality associated with cardiac arrest. Clinical strategies to reduce the likelihood of fatal cardiac arrest include the identification of high-risk patients, alteration of dialysis prescription to avoid large volume and electrolyte shifts, and reduction of myocardial ischemic burden. Implantable cardioverter defibrillators may potentially reduce the risk of fatal cardiac arrest in dialysis patients and improve long-term cardiac survival.