Frequent bleeding complications and poor long-term results have been reported after valve replacement in hemodialysis patients. We use mainly bileaflet mechanical valves with low-dose warfarin therapy (target international normalized ratio, 1.8-2.0) in such cases. Data of 27 hemodialysis patients undergoing isolated valve replacement from 1993 to 2002 were retrospectively analyzed. Bileaflet mechanical valves were selected in 23 patients and bioprostheses in 4. Those with mechanical valves were treated with mild anticoagulation therapy. There were 3 (11.1%) early deaths due to ischemic colitis, interstitial pneumonia, and ventricular arrhythmia. There were 3 late deaths and 5 bleeding complications during follow-up. The overall survival rate was 85.2% at 3 years and 72.9% at 5 years. The survival rate of patients with mechanical valves was 82.6% at 3 years and 76.7% at 5 years. One patient with a bioprosthesis experienced structural valvular deterioration after 3 years. The results demonstrate an acceptable long-term outcome. A bileaflet mechanical valve managed with mild anticoagulation therapy is a reasonable strategy for hemodialysis patients.