Objective: To explore the risk factors associated with osteoporosis (OP) and hip fractures in patients undergoing maintenance hemodialysis (MHD). Methods: 179 patients with MHD were selected as the research subjects, and were divided into medium and low-risk groups(n=105) and high-risk groups(n=74) based on the risk assessment results of OP or hip fracture using the FRAX system. The factors influencing the risk of OP or hip fracture in MHD patients was analyzed by univariate and multivariate Logistic regression analysis, the relationship between high risk of OP or hip fracture and indicators related to MHD patients were analyzed by Pearson correlation analysis, the predictive value of related indicators for the high risk of OP or hip fracture in MHD patients was analyzed by ROC curve analysis. Results: Univariate analysis showed that there were statistically significant differences in age, BMI, C-reactive protein(CRP), prealbumin(PAB), serum creatinine(Scr), serum uric acid(UA), and serum sodium between the two groups(P<0.05). Multivariate Logistic regression analysis demonstrated that low levels of PAB, Scr, and UA (OR=0.901,95%CI:0.836~0.965,OR=0.996,95%CI:0.994~0.998, OR=0.994,95% CI:0.989~0.999,respectively), as well as comorbid hypertension(OR=4.507,95% CI:1.478~14.559), were independently associated with a high risk of osteoporotic or hip fractures(P<0.05). The Pearson correlation analysis results showed that the high risk of OP or hip fracture was negatively correlated with serum iron, albumin PAB, Urea nitrogen Scr, UA, Blood phosphorus(P<0.05). ROC curve analysis revealed that a combined model of PAB, Scr, UA, and hypertension yielded an AUC of 0.840 (95% CI:0.783~0.897,P <0.001), with a sensitivity of 67.6% and a specificity of 82.9%. Conclusion: This study indicates that decreased levels of PAB, Scr, and UA, along with hypertension, are significant risk factors for fractures in MHD patients. Close monitoring of these indicators and strict blood pressure management are recommended to reduce fracture risk. These findings provide a valuable reference for individualized risk assessment in clinical practice.