Cardiovascular disease is the major cause of morbidity and mortality in patients with chronic kidney disease (CKD). Cardiac event rate rises as the glomerular filtration rate decreases, particularly below 60 ml/min/1.73m2. This risk remains even after adjustment for traditional risk factors. In patients with end stage renal failure (ESRF), death rates from cardiovascular disease are 20 to 40 times higher than in the general population and make up 40% of all-cause mortality. Furthermore, 72% patients with ESRF who suffer an acute myocardial infarction are dead within 2 years. Interestingly, whilst coronary artery atherosclerosis is more common in patients with CKD and risk of plaque rupture greater, only a third of the cardiac events in dialysis patients are associated with myocardial infarction; two thirds are due to sudden cardiac death or cardiac failure. Taken together, these observations suggest there is a more complex pattern of cardiovascular injury in patients with kidney disease. We propose to review the current understanding of vascular disease in CKD, the relation of vascular disease to cardiac disease and outcomes, using accumulating data regarding both acute and chronic inflammation. We postulate that the complex pattern of cardiovascular injury is due to these processes, which are understudied and under-recognized and are likely to be modified in the context of CKD. We suggest a direction of study, which may help to identify the nature of the vascular injury in CKD, understand the impact of this on cellular and clinical events, and ultimately help to design interventional studies targeted at specific patient groups.