Disorders of lipoprotein metabolism may have clinical implications as determinants of cardiovascular risk in patients with end-stage renal disease (ESRD). However, the role of hypertriglyceridemia or other parameters of lipoprotein metabolism as predictors of clinical measures of outcome during ESRD treatment is currently unknown. We determined the relationship between blood lipid, lipoprotein-cholesterol, apoprotein levels and the risk of cardiovascular death during 48 months of hemodialysis treatment in a prospective study of 129 patients with ESRD. Although serum triglyceride levels were increased in patients with preexisting cardiovascular disease, they were unrelated to clinical outcome during the period of follow-up. In contrast, lipoprotein(a) was an independent predictor of the risk of deaths attributable to cardiovascular disease during the prospective period of follow-up. Although these findings do not exclude the possibility that hypertriglyceridemic hemodialysis patients have atherogenic lipoproteins or associated metabolic conditions that predispose to cardiovascular death, our findings suggest that measurements of serum triglyceride concentration may not improve the cardiovascular risk assessment of hemodialysis patients.