Worldwide, there are 3 million patients that receive dialysis for end-stage kidney disease, with over 2700 in New Zealand. This number is steadily growing. The average survival for dialysis patients is only 3 years. The most common cause of death is from cardiovascular disease. Spironolactone prevents cardiac disease and sudden death in patients that do not require dialysis. In small trials of dialysis patients, spironolactone has been shown to reduce cardiovascular mortality. However, these trials were at high risk of bias, and suggested possible safety concerns. ACHIEVE is a large, randomised, multinational trial that will reliably determine whether spironolactone 25 mg daily will safely reduce cardiovascular mortality and hospitalisations in dialysis patients. The New Zealand team will enroll local patients into the trial and lead a sub-study of markers of cardiac function to provide unique understanding of the pathophysiology of heart disease to aid in targeting future therapies.