Left ventricular (LV) hypertrophy is common in end-stage renal disease, yet the factors associated with its development are poorly understood. LV mass index was determined by echocardiography in 78 patients who had been treated by dialysis for at least 3 months. A significant relation was evident between anemia and LV hypertrophy. The mean LV mass index was 158 +/- 6 g/m2 (mean +/- standard error) in patients in the lowest quartile of serum hemoglobin and 140 +/- 10, 132 +/- 7 and 120 +/- 8 g/m2 in the second, third and uppermost quartiles, respectively (p = 0.005). This relation persisted after adjusting for systolic blood pressure, treatment mode and suspected coronary artery disease. Forty-eight patients had paired studies. In these, LV mass index increased as hemoglobin decreased (coefficient = -0.81 g/m2/g/liter, p less than 0.025). These data indicate that anemia contributes to the development of LV hypertrophy in patients with end-stage renal disease.