Background <p>Patients receiving maintenance dialysis experience exceptionally high cardiovascular morbidity and mortality. Lipoprotein(a) [Lp(a)] is an established cardiovascular risk factor in the general population; however, its prognostic significance in dialysis populations remains uncertain.</p> Methods <p>A systematic review and meta-analysis of observational cohort studies evaluating circulating Lp(a) levels and adverse cardiovascular outcomes in maintenance dialysis patients were conducted. MEDLINE, Scopus, Web of Science, and CENTRAL were searched from inception through May 5, 2026. The outcomes included all-cause mortality, cardiovascular mortality, and MACEs. Random-effects meta-analysis was performed when at least two studies reported comparable adjusted hazard ratios; pooled analyses based on very few studies were considered exploratory.</p> Results <p>Fifteen reports representing 14 unique cohorts and 6380 dialysis patients were included. Nine studies evaluated hemodialysis populations exclusively, three evaluated peritoneal dialysis populations, and two evaluated mixed dialysis cohorts. Exploratory meta-analyses revealed associations between elevated Lp(a) levels and all-cause mortality (HR: 1.58; 95% CI: 1.24–2.02), cardiovascular mortality (HR: 2.07; 95% CI: 1.22–3.50), and MACE (HR: 1.56; 95% CI: 1.28–1.90). Certainty was low for MACE and very low for mortality outcomes.</p> Conclusions <p>Available evidence suggests an association between high Lp(a) concentrations and mortality and adverse cardiovascular events in maintenance dialysis patients. However, routine clinical use for cardiovascular risk stratification cannot yet be recommended because thresholds, assay standardization, incremental predictive value, and treatment implications remain unresolved.</p> Trial registration <p><a href="https://dx.doi.org/10.17504/protocols.io.dm6gp7491gzp/v1">https://dx.doi.org/10.17504/protocols.io.dm6gp7491gzp/v1</a>.</p>