To evaluate the prevalence of cardiac disease and its risk factors at the start of dialysis, we analyzed the demographic, clinical, echocardiographic, and laboratory data including ACE gene polymorphism of 111 end-stage renal disease(ESRD) patients who survived at least 6 months and had an echocardiogram within 6 months from the initiation of hemodialysis Clinically, 24% of the patients had congestive heart failure and 14% had ischemic heart disease. Congestive heart failure was associated with diabetes(56% vs. 32%, P=0.03), higher plasma homocysteine(24.5 micromol/l vs. 20.7 micromol/l, P=0.01), and lower parathyroid hormone(<60pg/ml; 46% vs. 14%, P= 0.004). Ischemic heart disease was associated with older age(62 vs. 48, P=0.001), diabetes(67% vs. 33%, P=0.01), hypoalbuminemia(3.1g/dl vs. 3.4g/dl, P=0.03) and lower parathyroid hormone(&60pg/ml; 47% vs. 18%, P=0.04). Echocardiographically, left ventricular hypertrophy (LVH) was present in 89% of the patients of whom in detail 70% had concentric left ventricular hypertrophy(CLVH), 18% had left ventricular dilatation (LD), and 12% had systolic dysfunction(SD). The following associates were found:LVH group-diabetes(41% vs. 9%, P=0.04) and smoking(34% vs. 2%, P=0.01), CLVH group-hypoalbuminemia(3.3g/dl vs. 3.6g/dl, P=0.08), and diabetes(45% vs. 26%, P=0.048), SD group-high cholesterolemia(205mg/dl vs. 168mg/ dl, P=0.01). High diastolic blood pressure was an independent predictor of severe LVH in multivariate logistic analysis(relative risk=1.46, P=0.05). In conclusion, LVH was highly prevalent in ESRD patients starting hemodialysis. Diastolic hypertension was independently associated with severe LVH and there was no association between ACE gene polymorphism and cardiovascular disease.