Calcium and phosphate imbalances are important mutable risk factors for cardiovascular disease in chronic kidney disease (CKD). Nearly all dialysis patients require phosphate binders. These include traditional calcium-based compounds and, more recently, the calcium-free, metal-free, non-absorbed agent, sevelamer hydrochloride. Both binder types reduce serum phosphorus, but differ with respect to calcium load and metabolism. Absorption from calcium-based agents very likely promotes positive total calcium balance in many patients. Positive calcium balance is inappropriate in adults and may promote or accelerate soft-tissue and vascular calcification even in the absence of hypercalcemia. Calcium accumulation in heart and vascular tissues contributes to rapidly progressive cardiovascular calcification – a strong predictor of cardiovascular and all-cause mortality in stage 5 CKD. More than two-thirds of stage 5 CKD patients have calcification scores above the 75th percentile for matched controls – scores associated with extremely high risk of cardiovascular events and death.