 The pathophysiology of cardiovascular disease in renal failure is poorly understood but as renal function declines, a range of abnormalities occur that may exert adverse effects upon the cardiovascular system. Hypertension, chronic anaemia and activation of the renin-angiotensin-aldosterone system RAAS and sympathetic nervous system all contribute to the development of myocardial hypertrophy and fibrosis. The same abnormalities may also lead to muscular hypertrophy and fibrosis of the arterial walls including the aorta. In combination with an increase in extracellular matrix, loss of elastic fibres and diffuse medial calcification, the arterial wall changes lead to arterial stiffening. In addition to these adverse haemodynamic and structural changes, endothelial injury, the first physiological manifestation of atherosclerosis, occurs early in the course of renal failure. 