Vascular calcification is common in patients with end-stage renal disease (ESRD) who are treated with regular dialysis, and it may contribute to the very high mortality rate from cardiovascular causes in such patients. Arterial calcification in those with chronic renal failure can result from the deposition of mineral along the intimal layer of arteries in conjunction with atherosclerotic plaques or from calcium deposition in the medial wall of arteries that is due, at least in part, to disturbances in mineral metabolism. Several reports indicate that coronary artery calcification as measured by electron-beam computed tomography (EBCT) is common and often quite extensive in patients with ESRD, but the clinical significance of this finding remains uncertain. EBCT measurements of coronary artery calcification have been shown to be a useful marker of atherosclerotic burden in the general population, and values serve to predict the risk of adverse cardiovascular events. By contrast, the relationship between coronary artery calcification scores as measured by EBCT and clinically significant coronary artery lesions has not been studied adequately in patients with ESRD. Indeed, calcium accumulation in the coronary arteries and other systemic vessels in patients with chronic renal failure is probably attributable to both intimal and medial wall calcification. Concurrent assessments using coronary angiography and EBCT are needed to determine the diagnostic value of EBCT as a predictor of cardiovascular disease in patients with ESRD. Despite the shortcomings of currently available data, the technique of EBCT makes it possible to detect the presence and to monitor the progression of coronary calcification in those undergoing long-term dialysis. Studies using this non-invasive diagnostic method may provide important new information about factors that initiate the development and mediate the progression of arterial calcification in patients with ESRD.