The pathogenesis of cardiovascular disease caused by mineral bone disorder in CKD. Elevated phosphorus and PTH result in vascular calcification through effects on vascular smooth muscle cells (SMC) and endothelial cells (EC). This, in turn, leads to vascular stiffness and left ventricular hypertrophy (LVH). Elevated fibroblast growth factor 23 (FGF-23) lowers 1,25-dihydroxyvitamin D (1,25(OH)2D) level by inhibiting 1α-hydroxylase and activating 24-hydroxylase, the elimination pathway for 25-hydroxyvitamin D (25(OH)D). Vitamin D deficiency results in increased renin and hypertension which, in turn, results in LVH. FGF-23 itself can also cause LVH. Abbreviations: HTN, hypertension; Pi, inorganic phosphate.