To identify the risk factors of stroke in patients receiving maintenance hemodialysis, we conducted a prospective study on patients in Okinawa, Japan. Patients with end-stage renal disease who were treated with maintenance hemodialysis before the end of 1990 and were alive on January 1, 1991 (N = 1,243) were studied. Medical records and pertinent data as of January 1, 1991 were compiled. All occurrences of stroke were recorded throughout the follow-up period, and until the end of 1995. The duration of observation was 5,110.3 patient-years. A total of 90 cases of stroke were observed, including 63 (70.0%) cerebral hemorrhage, 20 (22.2%) cerebral infarction, and 7 (7.8%) subarachnoid hemorrhage. Multiple logistic analysis identified hypertension as an independent predictor of stroke, with an odds ratio of 2.38 and a 95% confidence interval from 1.26 to 4.50. The present study demonstrates that the high incidence of stroke is at least partially explained by insufficient control of hypertension. Every effort to control hypertension is warranted in chronic dialysis patients.