Preliminary data suggest that defensive profile of hemodialysis (HD) patients might influence adaptation to the disease. However, the association of defense mechanisms with health-related quality of life (HRQoL) of HD patients remains unknown. In this cross-sectional investigation, 170 HD patients and 170 age- and sex-matched healthy participants had their psychological profile assessed with the Defense Style Questionnaire–40 and the Hospital Anxiety and Depression Scale. Furthermore, the HD patients had their HRQoL measured with the World Health Organization Quality of Life instrument–abbreviated version. The HD patients had a more neurotic and immature defensive profile. Splitting, projection, reaction formation, and denial were significantly associated with impaired HRQoL, independent of psychological distress. Somatization was an independent correlate of worse overall and physical HRQoL. These findings suggest that, apart from the treatment of psychological distress symptoms, clinicians should also consider the defensive profile of HD patients because it is independently associated with HRQoL and may be amenable to treatment.