Cardiac disease is a major cause of mortality and morbidity in hemodial ysis patients. Left ventricular hypertrophy(LVH) is an independent cardiac risk factor in these patients. To evaluate the prevalence and risk factors of echocardiographic LVH at the time of starting hemodialysis and its progression, we performed a prospective study. From Jun. 1994 to Feb. 1997, 111 patients with ESRD on starting hemodialysis were included. They received baseline echocardiography within six months from the initiation of hemodialysis. LVH was highly prevalent in ESRD patients at the time of starting hemodialysis (82% of 111 ESRD patients). Among them, 32 patients, who had LVH on baseline echocardiography, received follow-up echocardiography. At the time of second echocardiography, they had no clinical events such as angina, myocardial infarction, congestive heart failure and cerebrovascular accident. Follow-up echocardiography was done after 15 months(range; 9-24 months). LVH was defined as the left ventricular mass index(LVMI) greater than 131g/m2 in male, and 100g/m2 in female. Progressive LVH was defined as the follow-up LVMI larger than 105% of the baseline LVMI. We measured hemoglobin, blood urea nitrogen, creatinine, cholesterol, albumin, prealbumin, parathyroid hormone, Kt/V, nPCR, fibrinogen, homocysteine and ACE gene polymorphism. The median age was 55 years old(range; 19-78) and 50% of the patients had diabetes mellitus. Progressive LVH occurred in 19 patients(M:F= 12:7). Progressive LVH was associated with lower diastolic blood pressure(81+/-11 vs. 90+/-12mmHg, P= 0.036) and lower serum albumin level(3.5+/-0.4 vs. 3.9+/-0.4g/dl, P=0.009). Serum albumin level was well correlated to deltaLVMI(follow-up LVMI minus baseline LVMI) negatively(r=-0.4198, P=0.017). Hypoalbuminemia was an independent risk factor for progressive LVH using multiple logistic regression analysis(R.R.=1.288, P=0.046). Progressive LVH was not associated with age, gender, diabetes mellitus, smoking history and other laboratory parameters. In conclusion, LVH was highly prevalent in hemodialysis patients on starting hemodialysis. Progressive LVH occurred in 59% of hemodialysis patients, and hypoalbuminemia was a risk factor for progressive LVH in these patients.