The burden of ischemic heart disease is high in dialysis patients. Ischemia may result from atherosclerotic and nonatherosclerotic disease and may cause myocardial infarction and angina. The impact of diminished perfusion is intricately associated with the underlying cardiomyopathy, both of which predispose to heart failure. The etiology of ischemia is complex and associated with the underlying cardiomyopathy, whether it be concentric left ventricular hypertrophy, left ventricular dilatation, or systolic dysfunction. Hypertension, diabetes, dyslipidemia, abnormalities of divalent ion metabolism, hypoalbuminemia, and left ventricular hypertrophy are probably adverse risk factors for ischemia, but the relative importance of each is unknown.