Objective  Swollen hand  syndrome is a common vascular access complication in maintenance hemodialysis (MHD) patients. This study aimed to explore the risk factors for hand swelling at arteriovenous fistula (AVF) side in MHD patients, so as to provide theoretical evidences for early identification and clinical intervention of hand swelling syndrome.  Methods  This was a cross-sectional study. A total of 422 MHD patients treated at the Blood Purification Center of Guangdong Provincial People’s Hospital from July to August 2025 were enrolled and divided into two groups based on the presence or absence of hand swelling. General information, underlying diseases, vascular access history and arm circumference measurements at multiple sites were collected. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for hand swelling.  Results  Among the 422 MHD patients with functional AVFs, the incidence of hand swelling was 15.6% (66/422). Significant intergroup differences were observed in gender (F=14.120, P＜0.001), history of internal jugular vein catheterization on AVF side (F=10.156, P=0.001), history of previous AVF creation (F=5.376, P=0.020), and circumference differences at lateral wrist (F=11.972, P＜0.001), mid-forearm (F=16.553, P＜0.001) and mid-upper arm (F=40.083, P＜0.001) between hand swelling group and non-hand swelling group. Multivariate logistic regression demonstrated that mid-upper arm circumference difference between the two arms (OR=3.526, 95% CI：2.494～4.985, P＜0.001), high-pitched murmur at stenosis site (OR=4.675, 95% CI：2.018～10.827, P＜0.001), reduced AVF thrill (OR=5.080,  95% CI：1.372～18.807, P=0.015), age (OR=0.967, 95% CI：0.955～0.980, P＜0.001), and gender (OR=0.375, 95% CI：0.197～0.716, P=0.003) were the risk factors for the presence of hand swelling at AVF side.  Conclusions  Monitoring of mid-upper arm circumference and auscultation to detect stenosis in AVF should be regularly carried out to reveal the risk factors for hand swelling during the use of AVF for blood access, especially for female and younger MHD patients. Standardized surveillance of arm circumference differences combined with ultrasonography facilitate early intervention and adverse outcome prevention of hand swelling syndrome.