Higher calcium-phosphate products and the cumulative dose of oral calcium-based phosphate binders correlate with the extent and progression of arterial calcification in dialysis [33] and stage 3 or 4 CKD patients. Interestingly, serum phosphate levels were associated with increased rates of death and myocardial infarction in patients with stage 3 or 4 CKD [34,35]. This suggests that arterial calcification results in clinical morbidity and mortality in this patient population. Poorly controlled metabolic bone disease contributes to vascular calcification, which promotes arteriolosclerosis and increases vascular wall stiffness. Aortic stiffness is an independent predictor of total and cardiovascular mortality, coronary artery disease (CAD), and fatal stroke in patients with hypertension. One study of 96 patients, aged 18 to 70 with a creatinine clearances ranging from 15 to 90 mL/min per 1.73 m2 , found coronary calcification in 64%, and severe calcification present in 23% of patients [36]. Inflammation is a nontraditional risk factor believed to play a role in mediating cardiovascular risk in CKD. Markers of inflammation are often elevated in CKD patients and are predictive of cardiovascular risk in this population. Some, but not all studies, have found that serum C-reactive protein (CRP) levels predict cardiovascular outcomes in CKD patients. Menon and Sarnak [37] analyzed samples obtained from the Modification of Diet in Renal Disease study patients (all had stage 3, 4, or 5 CKD at enrollment), measuring CRP concentration and analyzing its relationship to long-term outcomes. With a 10-year median follow-up period, all-cause mortality was 20% and cardiovascular mortality was 10%. High CRP was an independent predictor of all-cause and cardiovascular mortality after investigators adjusted for confounding variables. The authors concluded that elevated CRP is useful for predicting outcomes in CKD patients. Proteinuria, a hallmark of renal impairment, is associated with an increased risk for cardiovascular disease and early cardiovascular mortality in patients with and without diabetes and hypertension [38,39]. This association was first demonstrated by the Framingham Heart Study investigators. More recently, Gerstein and colleagues [40], in a cohort of more than 9000 individuals enrolled in the Heart Outcomes Prevention Evaluation (HOPE) trial, noted an increased relative risk in the primary aggregate outcome of myocardial infarction, stroke, and cardiovascular death in microalbuminuric (urine albumin excretion 30 mg/24 h) subjects with and without diabetes (1.97 and 1.61, respectively). The risk associated with the presence of microalbuminuria increased progressively with increasing absolute levels of microalbuminuria. CKD patients are more likely to develop congestive heart failure (CHF). Bibbins-Domingo and colleagues [41] evaluated the association between CHRONIC KIDNEY DISEASE AND ITS COMPLICATIONS 335 CKD and new-onset CHF in African and Caucasians Americans. In the study, enrollees were stratified by cystatin C- and serum creatinine-based measurements of renal function. Investigators noted that risk for developing CHF correlated with the degree of renal impairment. A meta-analysis (16 studies, which included 80,098 hospitalized and nonhospitalized patients with CHF) evaluated the prevalence and mortality risk associated with the presence of CKD in patients with CHF [42]. The eGFR was less than 90 mL/min in 63% of patients included in the analysis. Approximately 30% of these patients were found to have moderate to severe renal impairment. In 11 of the 16 studies reporting all-cause mortality rates for follow-up after 1 year or more (range 1.0–11.7 years), 26% of patients without renal impairment, 42% with any renal impairment, and 51% with moderate to severe impairment died. A combined unadjusted mortality risk of relative risk (RR) ¼ 1.48, 95% confidence interval (CI) 1.45 to 1.52, P ! .001 was noted in patients with any renal impairment and RR ¼ 1.81, 95% CI 1.76 to 1.86, P ! .001 in patients with moderate to severe impairment. The authors concluded that renal impairment confers a clinically significant risk for excess mortality in patients with heart failure and the magnitude of the increased mortality risk is comparable to that associated with traditional prognostic indicators in heart failure such as ejection fraction. Progression of CKD is associated with a number of serious health complications, including increased incidence of cardiovascular disease (Fig. 1). Treating both traditional and nontraditional cardiovascular risk factors in individuals with CKD involves a multidisciplinary approach to care. Involvement of nurses, dieticians, educators, and surgeons increases optimization of care. Controlling blood pressure using K/DOQI guidelines (BP goal !130/85, !125/75 with proteinuria, !130/85 in the setting of diabetes), use of ACE inhibitor and/or angiotensin receptor blockers to reduce proteinuria, titrating insulin, and statin therapy to achieve appropriate glycated hemoglobin and serum cholesterol levels (!100 mg/dL), respectively, will reduce cardiovascular risk and prevent or slow the progression of kidney failure. Additional randomized trials are needed to establish treatment goals for cardioprotective therapies in this population of patients. Dyslipidemia Dyslipidemia is a major risk factor for