AIMS In children with chronic kidney disease (CKD), fetuin-A and fibroblast growth factor-23 (FGF-23) have been implicated in the mechanism and progression of several cardiac changes. This study aimed to determine the types and rates of cardiac changes in children with CKD and their association with fetuin-A, FGF-23, and other cardiovascular risk factors (CVRFs). METHODS This comparative cross-sectional study recruited 88 children (5-18 years): 27 CKD I with a glomerular filtration rate (GFR) >90 mL/min/1.73 m2 and 61 with a GFR of <90 mL/min/1.73 m2 (29 CKD II-IV, 32 CKD V-dialysis). Each patient had a short demographic and clinical history taken along with a physical examination. Blood was taken and sent for routine tests and for fetuin-A and FGF-23 assay. All patients had an echocardiogram to evaluate cardiac structure and function. RESULTS The distribution of left atrial diameter (LAD) and left ventricular (LV) mass differed significantly (p < 0.05) across the different CKD groups. Abnormal LAD was seen in 10% of patients; LV hypertrophy (LVH) in 27%; LV systolic dysfunction in 6% and diastolic dysfunction in 1 patient. Fetuin-A was the only independent predictor for abnormal LAD; mean arterial pressure was independently associated with concentric LVH, and age and hypoalbuminemia with eccentric LVH. Overall, the dialysis group had the highest rate of cardiac changes and associated risk factors. CONCLUSION Though not common, the importance of left atrial changes in children with CKD is highlighted along with the need to address modifiable CVRFs such as hypertension and hypoalbuminemia.