Cardiovascular disease causes the deaths of up to 50% of renal transplant recipients who have a functioning graft. As in other states of chronic kidney disease, both overload cardiomyopathy (chronic heart failure and left ventricular hypertrophy) and ischemic heart disease are evident; age and gender are important risk factors for both of these disorders. Potentially treatable risk factors include smoking, hyperlipidemia, diabetes and hypertension for ischemic heart disease, and anemia, hypertension and diabetes for cardiomyopathy. Although definitive evidence on the effectiveness of interventions is lacking, it seems reasonable to treat renal transplant recipients as patients at the highest risk of cardiovascular disease. Aggressive targeting of lifestyle factors, blood pressure, cholesterol and sugar regulation is likely to have a major impact on patient and graft survival and should be initiated well before transplantation. Maintenance of hemoglobin with erythropoietic agents is controversial but might improve quality of life. Although immunosuppressive agents have distinct effects on cardiovascular risk factors, the impact on outcomes is impossible to predict on the basis of current data, and no firm recommendations can be made.