Objective: Tissue Doppler imaging (TDI) has recently been proposed as a relatively preload-independent method to evaluate left ventricular diastolic function. We sought to investigate the higher-accuracy of TDI to assess diastolic function in end-stage renal disease (ESRD) patients on hemodialysis (HD) associated with a preload increase maneuver. Methods: Thirty-two consecutiveESRD patients (16 female, ages 48.8 ± 17.5 years, 14 ≤45 and 18 >45 years old) were evaluated. Measurements of E, A velocities and the E/A ratio from transmitral inflow pulsed wave Doppler, and E’, A’ velocities and the E’/A’ ratio from TDI were obtained 1 h before and 1 h after HD at baseline and with a preload increase maneuver. Results: The E/A ratio changed significantly in all patients aged >45 before and after HD with the preload increase maneuver. The E’/A’ ratio increased in all subjects with the preload increase maneuver before HD but did not change with the maneuver after HD in the euvolemic state in all patients. Conclusion: In ESRD patients on routine HD, TDI evaluation associated with a preload increase maneuver proved to be a more accurate method to identify diastolic dysfunction when the evaluation is performed in euvolemic patients after HD.