High Cardio-Ankle Vascular Index and Plasma Homocysteine Concentration Predict All-Cause Mortality During the First 3 Years of Hemodialysis in End-Stage Chronic Kidney Disease Patients

High cardio-ankle vascular index (CAVI) and elevated plasma homocysteine are non-traditional cardiovascular biomarkers associated with adverse outcomes in chronic kidney disease. This study evaluated the 3-year all-cause mortality rate and the prognostic value of CAVI and plasma homocysteine in patients with end-stage kidney disease (ESKD) initiating maintenance hemodialysis (MHD). A prospective longitudinal study was conducted in 178 patients with ESKD who initiated MHD at Duc Giang General Hospital, Hanoi, Vietnam, between August 2020 and August 2021. Plasma homocysteine was measured using a chemiluminescent assay, and CAVI was assessed before hemodialysis. Patients were followed for 3 years until August 2024. During follow-up, 42 patients died, yielding an all-cause mortality rate of 23.6%. Multivariable Cox regression analysis identified low HDL-C, elevated hs-CRP, elevated plasma homocysteine, and higher CAVI as independent factors associated with all-cause mortality (all p ≤ 0.001). Receiver operating characteristic analysis showed good discriminatory ability for predicting 3-year mortality, with an area under the curve (AUC) of 0.905 (p < 0.001; cutoff, 9.45; sensitivity, 83.3%; specificity, 84.6%) for CAVI and 0.865 (p < 0.001; cutoff, 32.23 μmol/L; sensitivity, 76.2%; specificity, 84.6%) for plasma homocysteine. Kaplan–Meier analysis demonstrated significantly lower survival in patients with higher CAVI and plasma homocysteine levels (log-rank, p < 0.001). In conclusion, higher CAVI and elevated plasma homocysteine were independently associated with increased all-cause mortality and showed good discriminatory ability for risk stratification during the first 3 years of MHD.