Vascular calcification is part of the definition of chronic kidney disease-mineral and bone disorder (CKD-MBD). It is also a surrogate parameter of cardiovascular and all-cause mortality risk in the CKD population. However, vascular calcification is not a homogenous entity, but a rather complex manifestation influenced by derangements of calcium and phosphate homeostasis, by dysregulated calcification inhibitors and promoters, and by the type of arterial disease (atherosclerosis vs arteriosclerosis). Despite the clear-cut risk association between the presence of vascular calcification and mortality, it is currently not well defined, how this knowledge about calcification should be translated into active clinical management. Further, the choice of the appropriate imaging test is a matter of debate. This article attempts to provide an update on insights into the pathophysiology of vascular calcification processes and a subjective view of the clinical consequences of management of CKD patients at risk.