Decreases in hemoglobin, erythropoietin, calcium, vitamin D, iron, and fetuin-A, as well as increases in serum phosphorous, parathyroid hormone (PTH), and fibroblast growth factor 23 (FGF-23), may induce myocyte hypertrophy, mechanical dysfunction, and myocardial fibrosis while simultaneously contributing to endothelial dysfunction, vascular stiffness, and vascular calcification. These changes ultimately induce systolic and diastolic function, salt and water retention, and the clinical syndrome of heart failure.