Objective The aim of this study was to investigate the predictive value of baseline serum albumin-cholesterol ratio (ACR) for the long-term survival of maintenance hemodialysis patients (MHD). Methods The clinical data of 308 MHD patients hospitalized in our center from January, 2010, to December, 2020, were retrospectively analyzed. According to the median ACR of 8.5, they were divided into a high-ACR group and a low-ACR group, with 154 cases in each group. The clinical relevant data of the two groups were compared. The Kaplan-Meier method was used to analyze the survival of the two groups, and the competing-risk model was used to further evaluate the difference in the death risk between the two groups after considering other outcomes that compete with death. Univariate analysis was used to analyze the impact of ACR on all-cause death and cardiovascular death in MHD patients. Results Kaplan-Meier analysis showed that the cumulative all-cause survlative cardiovascular disease survents in the high-ACR group were better than those in the low-ACR group. The competing-risk model showed that after considering other competing-risk factors other than the death outcome (such as conversion to peritoneal dialysis, kidney transplantation, etc.), the all-cause mortality rate in the low-ACR group was still higher than that in the high-ACR group (P＜0.05). The results of univariate analysis showed that being in the low-ACR group, decreased cholesterol and albumin were risk factors for all-cause death and cardiovascular death in MHD patients (P＜0.05). The results of drawing the ROC curve showed that the AUC values of ACR, albumin, and cholesterol for the long-term survival of MHD patients were 0.962, 0.765, and 0.891 respectively. The predictive value of ACR was greater than that of albumin and cholesterol, indicating good predictive value. Conclusion Low ACR is a risk factor for death in MHD patients, may have a predictive value for prognostic survival, and can be used as an important indicator. Medical staff should develop preventive and treatment measures for risk factors in MHD patients and patients with ACR＜8.5 to reduce the mortality rate