Convincing epidemiological data have repeatedly shown that increased phosphate levels as well as generous phosphate intakes are associated with unfavourable outcome both in normal and chronically impaired kidney disease (CKD) individuals. Indeed, evidence suggest that impaired phosphate metabolism is associated with markers of cardiovascular damage such as left ventricular hypertrophy, arterial stiffness or vascular calcification as well as mortality. Although current guidelines suggest phosphate control in CKD, evidence on the impact of different approaches to minimize phosphate burden on clinically meaningful outcome are still lacking. How to manipulate, when to start in the course of CKD and to what extent to control phosphate metabolism still remain to be addressed by properly designed clinical studies. Treatment decisions should be based on a risk–benefit assessment to avoid unnecessary exposure to potentially harmful side effects of available compounds. The focus and the ambition of this review are to summarize current evidence and to provide a point of care suggestion on the use of phosphate binders in CKD stage 3 and 4 patients.