Patients with end-stage renal disease (ESRD) have ≥3 times greater incidence and prevalence of coronary artery disease (CAD) than the general population. All dialysis patients must be considered at high risk for CAD, thus, managed accordingly. Classic CAD symptoms are often misleading in these patients, thus, are not helpful diagnostically. Conversely, age (≥50 years), diabetes or overt clinical cardiovascular disease (CVD) are associated with a > 40% prevalence of critical CAD and increased incidence of CV events. In this subgroup, coronary angiography should be considered the first and best diagnostic approach. Noninvasive investigation (cardiac scintigraphy/stress echocardiography), which provides adequate specificity but poor sensitivity, may be useful in younger individuals without associated comorbidities and in following-up patients without significant stenosis by angiography. The role of new noninvasive testing awaits more extensive evaluation. As prospective randomized trials have not examined the best treatment for dialysis patients with CAD, it remains undefined. Coronary artery bypass grafting appears superior to coronary angioplasty or stenting. No large study has compared medical treatment with coronary intervention, and few observations exist concerning the impact of modern cardioprotective therapy on outcomes. Based on studies in the general population, routine administration of at least few cardioprotective drugs (aspirin, -blockers, RAS inhibitors, statins) to all dialysis patients seems prudent.