Background <p>Dialysis adequacy is crucial for maintaining the health and quality of life of patients undergoing maintenance hemodialysis (MHD). Assessing its current status and identifying influencing factors is essential for optimizing treatment outcomes. We aimed to evaluate the status of dialysis adequacy in MHD patients and analyze the factors that affect it.</p> Methods <p>A cross-sectional study was conducted at a hemodialysis center from June to October 2024. A total of 232 MHD patients were included in the study. Data on demographics, hemodialysis parameters, and laboratory indicators were collected. Dialysis adequacy was assessed using the single pool Kt/V (spKt/V) method. Patients were categorized into adequate (spKt/V ≥ 1.2) and inadequate (spKt/V &lt; 1.2) dialysis groups.</p> Results <p>Of the 232 patients, 147 (63.36%) had adequate dialysis. Factors significantly associated with dialysis adequacy included sex, age, dialysis duration, dry weight, vascular access type, ultrafiltration volume, β2-microglobulin levels, and oxygen supplementation (<i>P</i> &lt; 0.05). Multiple linear regression analysis revealed that dialysis duration was an independent protective factor, whereas dry weight was an independent risk factor. These variables accounted for 79.30% of the variance in dialysis adequacy.</p> Conclusions <p>Dialysis adequacy in MHD patients requires further enhancement. Healthcare professionals can improve dialysis adequacy, ensure treatment efficacy, and enhance patients’ quality of life by adjusting dry weight, administering continuous low-flow oxygen inhalation during dialysis, and managing interdialytic weight gain.</p> Trial registration <p>Current Controlled Trials ISRCTN13609931, registered on 27 February 2025.</p>