Cardiovascular disease in the haemodialysis population continues to contribute to mortality and morbidity. Disorders of left ventricular geometry and function are highly prevalent and lead to increased mortality in this highly vulnerable population. Left ventricular dysfunction (LVDys), often as a result of hypertension, ischaemic cardiac disease or dilated cardiomyopathy, has not been uniformly defined in the literature making diagnosis and therapy problematic. Although routinely available, screening by echocardiography is critically volume dependent and prone to underestimation in left ventricular ejection fraction. Few randomized control trials are available to guide management with the majority of evidence requiring extrapolation from the non-dialysis population. Beyond medication, interventional cardiac procedures such as implantable cardiac defibrillator implantation and cardiac resynchronization therapy show promise. Conversion to alternative dialysis modalities such as peritoneal dialysis, short-daily or nocturnal dialysis have been attempted and are actively being explored.