We investigated 1) the association between serum albumin levels(Alb) at the initiation of dialysis and survival after a mean follow-up period of 30.1 +/- 23.1 months following the commencement of chronic dialysis, and 2) the factors associated with hypoalbuminemia at the initiation of dialysis in diabetic patients with end-stage renal failure(ESRF). A hundred and thirty diabetic patients who were initiated on chronic dialysis in our department between January 1992 and November 2000 were studied. Alb and some variables were collected at 12, 6, 3, and 1 month before the initiation of dialysis(-12, -6, -3, -1 M), at the initiation of dialysis(0 M), and 1, 6, and 12 months after commencing chronic dialysis(1, 6, 12 M). Multivariate logistic regression analysis showed that hypoalbuminemia(less than 3 g/d/) at 0 M was significantly associated with an increase in urinary protein excretion per 1 g/day during -12 M and -1 M and total blindness due to diabetic retinopathy(Odds ratio 1.41, 8.83, p = 0.01, 0.03). Cox's proportional-hazard model demonstrated that a decrease in Alb per 1 g/dl at 0 M was significantly associated with survival(Hazard ratio 3.69, p = 0.03, adjusted age, sex, mode of dialysis, and urinary protein excretion during -12 M and -1 M). In addition, a decrease in Alb between -1 M and 0 M was significantly associated with elevated C-reactive protein at 0 M and a decrease in hematocrit between -1 M and 0 M. In conclusion, hypoalbuminemia at the initiation of dialysis, from any cause other than proteinuria, was associated with a poor prognosis after commencing chronic dialysis in diabetic ESRF patients.