The advent of symptomatic coronary artery disease is a common and concerning occurrence in the clinical life of patients with advanced chronic kidney disease (CKD).1 Sadly, encounters with patients experiencing a recent onset or increase in the symptom burden of exercise-induced chest discomfort or dyspnea are common. Potentially difficult discussions about management options often ensue and commonly occur in stages. For example, in the absence of an acute coronary syndrome, a discussion might start with the pros and cons of initially attempting to optimize medical treatment while waiting on diagnostic tests and decisions about various management options (such as stress testing, cardiac catheterization, and possible revascularization) should symptoms fail to respond adequately to optimized medical therapy.