The prevalence of chronic kidney disease (CKD) is increasing in North America, with an attendant increase in cardiovascular complications. The bulk of the mortality and morbidity in CKD patients can be attributed to coronary artery disease (CAD), especially in the presence of diabetes mellitus. Thus, screening and diagnosis of CAD is particularly important in the management of these patients, especially during evaluation for renal transplantation. However, numerous limitations exist with noninvasive tests that cloud the ideal strategy for diagnosis. In addition, the optimal revascularization strategy (surgery versus percutaneous intervention) for CAD is controversial for these patients. Randomized trials are clearly needed; unfortunately, major cardiovascular trials usually exclude patients with significant renal dysfunction. The current diagnostic and revascularization strategy for CAD in CKD patients is discussed, highlighting current controversies that warrant further investigation.