Patients with kidney disease experience strikingly high cardiovascular risk in the absence of conventional cardiovascular risk factors, including smoking or elevation of cholesterol associated to low-density lipoprotein. Kidney failure remains independently associated with increased cardiovascular risk in patients with diabetes, underlining the specific adverse influence of kidney disease on cardiovascular risk. Vascular injury develops in asymptomatic patients with kidney failure early in the course of the disease. Defective arterial vasodilation, increased arterial stiffness, increased intima-media thickness, and vascular calcification develop in patients with kidney disease long before clinical evidence of cardiovascular events. Even mildly reduced kidney function is associated with subclinical vascular disease which is a predictor of worse cardiovascular outcome in patients with kidney failure, similarly to the general population and patients with diabetes. Insulin resistance is a typical feature of kidney disease that occurs during the entire span of the disorder, from mild dysfunction to the dialysis phase. Insulin resistance (or its clinical manifestations, the metabolic syndrome or its components) is independently associated with subclinical vascular injury in patients with kidney disease. Additionally, the risk for developing incident kidney disease and for rapid decline of kidney function is higher in patients with insulin resistance. Animal protein consumption increases dietary acid load and intensifies insulin resistance. Consistently, meat intake promotes diabetes, cardiovascular disease and kidney failure while consumption of plant-based food is protective against the development of vascular disease. Insulin resistance is a robust cardiovascular risk factor in the general population, patients with diabetes and patients with kidney disease.