Little is known regarding the natural longitudinal changes in cardiac structure and function in CKD. We hypothesized that baseline CKD stage is associated with progressive worsening in cardiac structure and function. We conducted a prospective longitudinal study, recruiting 300 patients with stages 3-5 CKD from a major regional tertiary center and university teaching hospital in Hong Kong. Baseline CKD stages were studied in relation to natural longitudinal changes in echocardiographic and tissue Doppler imagingderived parameters. Over 1 year, the prevalence of left ventricular (LV) hypertrophy increased from 40.3% to 48.9%, median left atrial volume index CKD is a global public health problem and a major risk factor for cardiovascular disease. 1,2 Cardiovascular mortality is estimated to be at least 10-to 100-fold higher in patients with ESRD than in the age-, race-, and sex-matched general population. 2 This higher mortality is attributed to an increased risk of developing accelerated atherosclerosis, vascular calcification, heart failure, and sudden cardiac death. 3 Even earlier stages of CKD are associated with an increased cardiovascular risk. 1,4,5 Of the various cardiovascular complications, left ventricular hypertrophy (LVH) is one of the most prevalent 6,7 and is predictive of an increased mortality and cardiovascular death. 8,9 More than 75% of patients with CKD already had established LVH at the time of dialysis initiation. 10 The prevalence of LVH in patients with CKD who are not undergoing dialysis was lower, ranging from 32% to 75%. 6,7,11,12 Notably, patients with an eGFR,30 ml/min per 1.73 m 2 showed a .2-fold increased risk of having LVH compared with those with an eGFR$60 ml/min per 1.73 m 2 , 6 suggesting that worsening kidney function or uremia, per se, may be an important contributing factor for LVH in CKD. Indeed, several previous cross-sectional studies have consistently shown an important inverse relationship between eGFR and left ventricular (LV) mass