Objective  To investigate the association between bone mineral density (BMD) and sarcopenia-related indicators and evaluate the predictive value of BMD for prognosis in patients undergoing maintenance hemodialysis (MHD). Methods This prospective cohort study enrolled MHD patients who received treatment at the Hemodialysis Center of the First Hospital of Hebei Medical University from June 1 to June 30, 2024. Baseline lumbar spine BMD was measured using quantitative computed tomography. Muscle function (handgrip strength, chair stand time, gait speed) and the skeletal muscle mass index (SMI) were assessed simultaneously. Clinical data and laboratory parameters were collected, and the patients were followed prospectively for 20 months. Multiple linear regression analysis was used to identify independent factors associated with BMD, and a Cox proportional hazards model was employed to assess the association with BMD and adverse clinical outcomes.  Results  A total of 125 MHD patients were included, with a mean BMD of (118.318±40.344) mg/cm³. Multiple linear regression revealed that increased age (β=-1.196, 95% CI:-1.797～
-0.595, P＜0.001) and prolonged chair stand time (β=-2.179, 95% CI:-3.968～-0.390, P=0.017) were independent risk factors for reduced BMD, while SMI was an independent protective factor (β=10.146, 95% CI: 3.550～16.742, P=0.003). During follow-up, BMD was an independent protective factor against cardio-cerebrovascular events in MHD patients (HR=0.990, 95% CI: 0.980～1.000, P=0.042).  Conclusion In MHD patients, increased age and impaired lower limb muscle function are independent risk factors for reduced BMD, while a higher SMI is a protective factor. Lower BMD is associated with an increased risk of cardio-cerebrovascular events in MHD patients.