Serum albumin, C-reactive protein (CRP), and the intima-medial thickness of the common carotid artery (CA-IMT) are associated with clinical outcomes in hemodialysis (HD) patients. However, it remains unclear which parameters are more reliable as predictors of long-term mortality. We measured serum albumin, CRP, and CA-IMT in 206 HD patients younger than 80 years old, and followed them for the next 10 years. One hundred sixty-eight patients (age: 57 +/- 11 years, time on HD: 11 +/- 7 years) were enrolled in the analyses. We divided all patients into three tertiles according to their albumin levels, and conducted multivariate analyses to examine the impact on 10-year mortality. Seventy-three (43.5%) patients had expired during the follow-up. Serum albumin was significantly lower in the expired patients than in the surviving patients (3.8 +/- 0.3 vs. 4.0 +/- 0.3, P<0.01), while CRP (4.7 +/- 5.0 vs. 2.8 +/- 3.5 g/L, P=0.01) and CA-IMT (0.70 +/- 0.15 vs. 0.59 +/- 0.11 mm, P<0.01) were significantly higher in the expired group. The multivariate analysis revealed that there was a significantly higher risk for total mortality in HD patients with serum albumin <3.8 g/dL (odds ratio 5.04 [95% CI: 1.30-19.60], P=0.02) when compared with those with albumin >4.1 g/dL. In contrast, CRP and CA-IMT did not associate with total death. It follows from these findings that serum albumin is more superior as a mortality predictor compared with CRP and CA-IMT in HD patients.