Cardiovascular disease (CVD) is the major cause of morbidity and mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). The increased prevalence of CVD in patients with renal dysfunction has been attributed to lack of effective prevention and low utilization of effective therapy. The optimal treatment of ischemic heart disease in ESRD patients before renal transplantation is controversial. Although no meta-analysis or pooled analysis of the data from small trials exists, it appears that percutaneous coronary intervention (PCI) provides excellent angiographic success but is associated with increased restenosis and the need for revascularization and that coronary artery bypass grafting (CABG), while associated with higher in-hospital morbidity and mortality, provides better overall long-term results and freedom from angina. Despite suboptimal results for percutaneous interventions in comparison with bypass surgery, PCI remains a viable option, especially for patients who are not candidates for surgery and those with disabling angina despite anti-anginal therapy. Regardless of the revascularization strategy used, outcomes of CABG or PCI in these patients are significantly worse than outcomes in the general population. The long-term benefit after revascularization and adjunctive medical therapy should be an area of intense future research. Studies should also be conducted to investigate the benefit and safety of therapies such as the long-term use of beta-blockers, statins, and renin-angiotensin-aldosterone axis inhibition in patients with CKD.