Numerous experimental and clinical studies have recently addressed the underlying mechanisms in particular the marked increase in cardiovascular mortality in patients with CKD. Hyperphosphatemia is a major problem in these patients with advanced stage of CKD. Calcium carbonate became the most widely used phosphate binders ; however, increasing evidence now suggests that prolonged use of these agents increases the total body calcium load, induces adynamic bone, and potentially increases the risk of cardiovascular and soft tissue calcification. Sevelamer is the first phosphate-binding agent that is non-absorbed, calcium-free, and metal-free. To date, this agent has been shown to effectively control serum phosphorus levels in patients with CKD. It may also attenuate coronary and aortic calcification and has a number of other beneficial effects on lipid metabolism and inflammation among others.