Introduction: Heart failure (HF) is a common consequence of chronic kidney disease (CKD) that portends a high mortality risk. The pathogenesis of HF in these patients (pts), largely related to cardiac abnormalities and volume handling, has not been fully characterized yet. Remodeling of the left atrium (LA), which is highly sensitive to volume overload and left ventricular (LV) filling pressures, might be a more sensitive marker and a potentially pathogenic factor of symptomatic status in this clinical setting. Therefore, we aimed to assess the LA remodeling and its relationship with HF symptoms in pts with CKD. Methods: We prospectively enrolled 62 pts (65 ± 11 years, 42 men) with CKD and normal LV ejection fraction, in sinus rhythm. For a subgroup of 16 pts we enrolled 16 age and gender matched normal subjects. LV filling pressures were assessed using the E/e’ ratio. Global longitudinal LV strain (GLS) and LA strain parameters: peak systolic LA strain (LAε) as an expression of LA reservoir function, early diastolic strain rate (ESr) for LA conduit function and late diastolic strain rate (ASr) for LA pump function were all assessed by 2D strain echocardiography. The functional status was defined according to the New York Heart Association (NYHA) classification. The stage of CKD has been established based on the glomerular filtration rate. Results: The etiology of CKD was: diabetic nephropathy (13 pts), nephroangiosclerosis (32 pts), tubulointerstitial nephropathy (14 pts) and chronic glomerulonephritis (3 pts). Fifteen pts were in NYHA class 1, 31 in NYHA class 2 and 16 in NYHA class 3. When compared to normal subjects, CKD pts had higher LV mass, E/e’, and lower values for GLS, LAε, ESr and ASr (p < 0.01). Symptomatic pts (NYHA class ≥ 2) were older, had higher LV mass, E/e’, and lower values for creatinine clearance, GLS and LA functional parameters than asymptomatic pts (p < 0.05 for all). In multivariate analysis, ASr was correlated with symptomatic status independently of age, etiology or severity of renal failure and LV systolic or diastolic dysfunction (p = 0.02, OR = 29.95% CI 1.58 – 536.20). Conclusions: In pts with CKD and normal LV ejection fraction, LA reservoir, conduit and booster pump function were significantly reduced. LA contractile function (ASr) was the main correlate of symptomatic status, suggesting that LA dysfunction might better reflect cardiac involvement with clinical impact in this pathology.