Arterial wave reflections (AWRs), an important determinant of cardiac afterload, are increased in hemodialysis patients. However, an association between AWRs and left ventricular hypertrophy has not been established in these subjects. We therefore sought an association between these two parameters in a cross-sectional study of two outpatient hemodialysis populations. AWRs were quantified (augmentation index, percent) as the ratio of the height of the late systolic peak to the total height of the carotid pulse wave recorded with a micromanometer-tipped probe. AWRs were determined in 44 hemodialysis patients, 22 with pronounced AWRs (group A: augmentation index >12%), and 22 with small or moderate AWRs (group B: augmentation index <12%). The groups were matched for age, sex, blood pressure, and hemodialysis duration. Left ventricular size was determined by echocardiography. Despite lower body size (P<.005) and similar blood pressure, cardiac output, peripheral resistance, and aortic pulse wave velocity, group A patients had greater left ventricular mass (P<.01). For the population as a whole, left ventricular mass and AWRs were positively correlated (P<.0001) independent of age, blood pressure, hemodialysis duration, or body size. Lesser body height was the principal factor associated with increased AWRs in group A (P<.001). We conclude that in hemodialysis patients AWRs are associated with the development of left ventricular hypertrophy and that small body height is a risk factor for long-term cardiovascular complications.