A large proportion of late renal allograft failures are attributable to patient death with a functioning graft, with almost half of the deaths related to cardiovascular events. Using data from the Framingham Heart Study and our own renal transplant population, risk factors for cardiovascular disease in the general population, such as hypertension, hyperlipidemia, and cigarette smoking, were found to be predictive in renal transplant recipients. However, diabetes mellitus dramatically elevated the risk in renal transplantation. Also, two or more acute rejection episodes in the first year after transplantation were associated with a greater risk, whereas pretransplantation nephrectomy and higher serum albumin levels reduced the risk for ischemic heart events. Pretransplantation screening assists identification of patients who are at risk of, or who have preexisting, cardiovascular disease. Management interventions such as antihypertensives, lipid-lowering agents, antidiabetic therapy, aspirin prophylaxis, and smoking cessation have a positive impact on known risk factors for cardiovascular disease, and their use may decrease cardiovascular morbidity and mortality in renal transplant recipients.