Despite the excess CV risk, a consistent proportion of ESRD patients are not given ACE inhibitor therapy because of concern of hyperkalemia. Others, on the contrary, are treated on the basis of results of available trials. However, whether data in subjects without renal insufficiency can be generalized also to those with ESRD is unknown. This is an itchy point since dialysis patients might respond differently to therapies of proven benefits in non-ESRD patients. For instance, data from the German Diabetes and Dialysis study showed that, unlike in the general population, HmGCoA inhibitor therapy failed to decrease CV mortality in a hemodialysis population. Thus, ad hoc studies in the ESRD population are urgently needed. A recent trial, the Fosinopril in Dialysis (FOSIDIAL) study, tried to address this issue, but was clearly underpowered and results were inconclusive. However, evidence of a non significant trend to less cardiovascular events in the ACE inhibitor arm, suggests that ACE inhibitors might have a specific cardioprotective effect also in this population.