Cardiovascular morbidity and mortality remain high in ESRD patients. Lipid abnormalities in CAPD may be more important than in hemodialysis. Vessel calcification may have a role in atherosclerotic heart disease, but this is only an inference from several clinical observations, and it remains to be defined more clearly as a risk factor. Left ventricular hypertrophy is frequent in this patient population, and is associated with specific clinical patterns and an increased risk of death. Erythropoietin treatment of anemia and tight blood pressure controls have proved to help in reversing severe left ventricular hypertrophy. Finally, we describe a syndrome of the hypertrophic, high cardiac output hemodialysis heart, which is characterized by a high cardiac output in hemodialysis patients. It is associated with left ventricular hypertrophy and eventually right ventricular hypertrophy with tricuspid insufficiency. This may require fistula revision and even a switch peritoneal dialysis.