The etiology of VC is multifactorial in patients with ESRD, and it has been reported to involve aging, diabetes, smoking, oxidative stress, inflammation, hyperfibrinogenemia, dysregulation of fibroblast growth factor 23, intact parathyroid hormone, calcium and phosphorus, protein-energy wasting, loss of osteopontin and fetuin-A, the osteoprotegerin/receptor activator of NF-kB/receptor activator of the NF-kB ligand system, as well as an increase in sclerostin [31,32,33]. This evidence concerns the gene SPP1 and diabetes mellitus.