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Most of the vast endothelial surface area is part of the microcirculation, but most research in CKD-related cardiovascular disease (CVD) has been devoted to macrovascular complications. We have reviewed all publications evaluating structure and function of the microcirculation in humans with CKD and animals with experimental CKD. Microvascular rarefaction, defined as a loss of perfused microvessels resulting in a significant decrease in microvascular density, is a quintessential finding in these studies. The median microvascular density was reduced by 29% in skeletal muscle and 24% in the heart in animal models of CKD and by 32% in human biopsy, autopsy and imaging studies. CKD induces rarefaction due to the loss of coherent vessel systems distal to the level of smaller arterioles, generating a typical heterogeneous pattern with avascular patches, resulting in a dysfunctional endothelium with diminished perfusion, shunting and tissue hypoxia. Endothelial cell apoptosis, hypertension, multiple metabolic, endocrine and immune disturbances of the uremic milieu and specifically, a dysregulated angiogenesis, all contribute to the multifactorial pathogenesis. By setting the stage for the development of tissue fibrosis and end organ failure, microvascular rarefaction is a principal pathogenic factor in the development of severe organ dysfunction in CKD patients, especially CVD, cerebrovascular dysfunction, muscular atrophy, cachexia, and progression of kidney disease. Treatment strategies for microvascular disease are urgently needed.<\/jats:p>","DOI":"10.1042\/cs20200279","type":"journal-article","created":{"date-parts":[[2020,6,16]],"date-time":"2020-06-16T06:11:11Z","timestamp":1592287871000},"page":"1333-1356","update-policy":"https:\/\/doi.org\/10.1042\/crossmark_policy","source":"Crossref","is-referenced-by-count":135,"title":["Microvascular disease in chronic kidney disease: the base of the iceberg in cardiovascular comorbidity"],"prefix":"10.1042","volume":"134","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6783-3822","authenticated-orcid":false,"given":"Uwe","family":"Querfeld","sequence":"first","affiliation":[{"name":"Department of Pediatrics, Division of Gastroenterology, Nephrology and Metabolic Medicine, Charit\u00e9 - Universit\u00e4tsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert\u00a0H.","family":"Mak","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Gastroenterology, Nephrology and Metabolic Medicine, Charit\u00e9 - Universit\u00e4tsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Axel\u00a0Radlach","family":"Pries","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, Division of Gastroenterology, Nephrology and Metabolic Medicine, Charit\u00e9 - Universit\u00e4tsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"288","published-online":{"date-parts":[[2020,6,16]]},"reference":[{"key":"2021113011131796400_B1","doi-asserted-by":"publisher","first-page":"168","DOI":"10.1161\/01.ATV.0000051384.43104.FC","article-title":"Endothelial dysfunction: a marker of atherosclerotic risk","volume":"23","author":"Bonetti","year":"2003","journal-title":"Arterioscler. 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