Cardiovascular disease (CVD) is the most common cause of death in patients with chronic kidney disease (CKD). Structural and functional vascular abnormalities and arterial calcification begin early in the course of renal decline and can be found even in children, contributing to their high mortality risk. Here, I discuss the burden of CVD in children with CKD; currently available methods of monitoring cardiac and vascular damage; the sensitivity of monitoring methods; and whether there is a need for regular monitoring in children with CKD.