Background Chronic kidney disease (CKD) is associated with increased risk of coronary heart disease. However, information regarding the histopathologic characteristics of coronary atherosclerosis in individuals with CKD is scarce. This study investigated the relationship between CKD and severity of coronary atherosclerosis in population-based autopsy samples. Study Design Cross-sectional study. Setting & Participants 126 individuals randomly selected from 844 consecutive population-based autopsy samples. Predictor Estimated glomerular filtration rate (eGFR) calculated using the 6-variable Modification of Diet in Renal Disease (MDRD) Study equation. Outcomes Severity of atherosclerosis in 3 main coronary arteries, including atherosclerotic lesion types defined using the American Heart Association classification; stenosis rates; and coronary calcified lesions. Measurements The relationship between CKD and severity of coronary atherosclerosis was evaluated using generalized estimating equation methods. Results Frequencies of advanced atherosclerotic lesions increased gradually as eGFR decreased (33.6%, 41.7%, 52.3%, and 52.8% for eGFRs ≥60, 45-59, 30-44, and <30 mL/min/1.73 m2 , respectively; P for trend = 0.006). This relationship was substantially unchanged even after adjustment for potential confounding factors (ORs, 1.40 95% CI, 0.76-2.55, 2.02 95% CI, 0.99-4.15, and 3.02 95% CI, 1.22-7.49 for eGFRs of 45-59, 30-44, and <30 mL/min/1.73 m2 , respectively). Frequencies of calcified lesions of coronary arteries also increased gradually with lower eGFRs ( P for trend = 0.02). Hypertension and diabetes were associated with increased risk of advanced coronary atherosclerosis and calcification of coronary arteries in individuals with decreased eGFR. Limitations Cross-sectional study, absence of data for proteinuria, and extremely high proportion of aged people. Conclusions The autopsy findings presented here suggest that CKD is associated significantly with severity of coronary atherosclerosis. Patients with CKD should be considered a high-risk population for advanced coronary atherosclerosis.