Background: Albuminuria is a powerful, independent, predictor of progression of renal disease, cardiovascular disease and death in people with renal disease, hypertension, diabetes, vascular disease, and in the general population. However, it is not known whether changes in albuminuria are predictive of cardiovascular outcome and mortality. Methods: In 23480 patients with vascular disease or complicated diabetes changes in albuminuria (at least doubling or halving) in spot urine from baseline to 2 years, measured in a central laboratory, were related to the incidence of cardiovascular and renal outcomes and total mortality over the subsequent 32 months. Results: An increase in albuminuria from baseline to 2 years (doubling or more), found in 28%, was associated with increased mortality [HR 1.47, 95 % CI 1.31–1.65, p < 0.0001], and a decrease in albuminuria (at least halving), noted in 21%, with reduced mortality [HR 0.85, 95% CI 0.74 - 0.98, p = 0.025] compared to those with lesser minor changes in albumin excretion, after adjustment for baseline albuminuria, initial blood pressure and its changes and other confounding factors. Changes in albuminuria were also significantly associated with cardiovascular death, composite cardiovascular outcomes (cardiovascular death, myocardial infarction, stroke and hospitalization for heart failure) and renal outcomes (dialysis or doubling of serum creatinine). Overall, all cause mortality increased by 19% and composite cardiovascular outcomes by 39% in patients with an increase in albuminuria (doubling or more) compared to those with minor changes in albuminuria. Conclusions: In patients with vascular disease, changes in albuminuria predict cardiovascular and renal outcomes, and mortality independent of baseline albuminuria. Thus, monitoring of albuminuria is a useful strategy for predicting cardiovascular risk.