Background: Cardiovascular complications in dialysis patients focused on atherosclerosis. Serum magnesium has a role in cardiovascular complications in dialysis patients. Objectives: This study aimed to study the correlation between serum magnesium level and atherosclerotic changes in patients on maintenance hemodialysis. Patients and methods: This prospective study included 60 patients with end-stage renal disease patients on maintenance HD, divided into Group I: (20 patients) with normal serum magnesium level (1.7 -2.8 mg/dl), Group II (20 patients) with low serum magnesium level (< 1.7mg/dl) and Group III (20 patients) with high serum magnesium level (> 2.8mg/dl.). Serum magnesium and lipid profile and intima-media thickness (IMT) of both common carotid arteries were measured. Results: Our results showed a significant negative association between level of serum Mg and IMT complex of both common carotid (P = 0.045) and ischemic heart disease in the studied patients (P = 0.012). The binary logistic regression for the predictors for IHD and CCA-IMT, we found that serum magnesium not an independent factor for atherosclerosis but we found that age and DM (P ˂ 0.001) followed by cholesterol and triglycerides (P ˂ 0.05) are the most independent factors for CCA-IMT. Also, age (with OR: 95% confidence Interval) (0.145:1.26-1.06) (P ˂ 0.001) and triglycerides (1.02:1.05-1.002), (P ˂ 0.05) are the independent factors for IHD. Conclusion: Our study revealed a significant inverse correlation between level of serum Mg and CCA-IMT and IHD in the studied HD patients. Thus, we suggest that regular screening of HD patients for serum Mg and CIMT with special consideration to diabetic and old patients is recommended to stratify their CV risk.