Background <p>Chronic kidney disease (CKD) progression to end-stage renal disease (ESRD) increases cardiovascular disease (CVD) risk, with coronary artery calcification (CAC) affecting 70% of Chinese maintenance hemodialysis (MHD) patients. Prolonged MHD treatment is linked to calcium-phosphorus imbalance and accelerated CAC progression. However, conflicting findings on CAC risk factors persist due to methodological heterogeneity in existing studies.</p> Objective <p>To systematically analyze the risk factors for coronary artery calcification in patients undergoing maintenance hemodialysis in China.</p> Methods <p>We conducted a computer-assisted search of ten databases, including PubMed, Web of Science, CBM, Wanfang, CNKI, and VIP, for observational studies (cohort, case–control, and cross-sectional studies) published from inception to October 21, 2024, on risk factors for coronary artery calcification (CAC) in Chinese patients with maintenance hemodialysis (MHD). The studies were independently screened by two investigators according to the PRISMA guidelines and diagnosed with coronary artery calcification through imaging techniques (CT). Odds ratios (<i>OR</i>s) and 95% confidence intervals (CIs) were used for the reported outcomes. The quality of the studies was assessed using the Newcastle–Ottawa Scale. A meta-analysis of the included data was performed using either a random effects model or a fixed effects model, we performed a meta-analysis using the Stata 17.0 software.</p> Results <p>The review included 24 studies with a total sample size of 2,875 patients. A meta-analysis of these 24 studies (<i>n</i> = 2875) found that diabetes mellitus (<i>OR</i> = 2.32, 95% CI 1.37–3.27) and elevated iPTH (<i>OR</i> = 1.59, 95% CI 1.21–1.96) were the strongest predictors of an increased risk of coronary artery calcification (CAC) in Chinese maintenance hemodialysis (MHD) patients. Additionally, elevated high-sensitivity C-reactive protein (hs-CRP) levels, elevated serum calcium, advanced age, longer duration of dialysis treatment, elevated serum phosphorus, and elevated sclerostin (SOST) levels were significant predictors of an increased risk of concurrent CAC in Chinese MHD patients. However, the correlation between hypertension, serum magnesium, fibroblast growth factor-23 (FGF-23), alkaline phosphatase (ALP), and MHD with concomitant CAC was not significant, likely due to the wide variation in sample size and study type.</p> Conclusion <p>Diabetes mellitus and elevated iPTH are the most significant clinical risk factors for coronary artery calcification (CAC) in Chinese maintenance hemodialysis (MHD) patients, and healthcare professionals should prioritize this population. Additionally, monitoring calcium and phosphorus metabolism, along with inflammatory markers (e.g., hs-CRP, SOST), can further reduce the risk of cardiovascular disease. Early health education and targeted, individualized treatment strategies for high-risk groups are recommended to prevent and delay the onset and progression of CAC in MHD patients.</p>