BACKGROUND: Maintenance hemodialysis (MHD) patients carry extremely high cardiovascular mortality, where pulmonary hypertension (PH) and vascular access are critical prognostic factors. However, previous survival studies seldom considered renal transplantation as a competing event, potentially biasing risk factor estimates, and the heterogeneity of mortality predictors across vascular access subtypes remains unclear. This study aimed to evaluate whether echocardiographic probability of PH is independently associated with all-cause mortality in MHD patients using a competing risk model. Secondary objectives included identifying additional clinical and echocardiographic predictors of mortality and comparing survival between vascular access types. Exploratory subgroup analyses by vascular access and construction of a nomogram were also performed. METHODS: This single-center retrospective cohort enrolled 749 MHD patients from the First Affiliated Hospital of Guangxi Medical University between May 2010 and May 2022. All-cause mortality was the primary endpoint, with renal transplantation as the competing event. Independent predictors were identified via the Fine-Gray model, and subgroup analyses were performed by tunneled cuffed catheter (TCC) and arteriovenous fistula/graft (AVF/AVG). RESULTS: During follow-up, 274 deaths and 64 renal transplantations occurred. Intermediate/high probability of PH, age, left atrial diameter, and right ventricular diameter (RVD) independently predicted mortality. Subgroups showed age and high PH predicted death in TCC patients, whereas age, intermediate/high PH, and RVD predicted death in AVF/AVG patients. No survival difference was found between groups. CONCLUSION: PH severity, age, and cardiac structural remodeling are independent mortality risk factors in MHD patients. Risk predictors vary by vascular access, and individualized cardiovascular stratification may improve long-term outcomes.