Serum phosphate has recently emerged as a cardiovascular risk factor in several populations, including patients with chronic kidney disease. Much of the adverse cardiovascular risk profile seen in chronic kidney disease can be attributed to structural heart disease, which appears to be driven by an increase in arterial stiffness. There is strong evidence linking phosphate to vascular calcification, which in turn causes arterial stiffening. In the following studies, phosphate is shown to be an independent predictor of renal function decline in patients with stage 2–4 chronic kidney disease. In addition, phosphate is shown to be independently associated with left ventricular mass, a predictor of cardiovascular morbidity and mortality. In the final study, the cardiovascular effects of reducing phosphate exposure with sevelamer carbonate, an oral, non-calcium-based phosphate binder, are assessed in a randomised, double blind, placebo-controlled trial of 120 patients with stage 3 chronic kidney disease. Although no demonstrable effects were seen on arterial stiffness, left ventricular mass, or left ventricular function, adherence to study medication was low given the high pill burden. Testing of this hypothesis may therefore require introduction of a therapy that effectively lowers phosphate exposure through a more acceptable dosing regimen.