Objectives: Vascular calcification (VC) is a commonly occurring and serious complication in end-stage renal disease (ESRD) patients that increases mortality. Vitamin K deficiency is well known to cause the occurrence of VC through the inactivation of Vitamin K dependent proteins (VKDP). We aim to investigate whether the easily measurable vitamin K absence II (PIVKA-II) can serve as a surrogate marker for predicting coronary artery calcification (CAC) in ESRD patients receiving hemodialysis and what factors influence CAC. Methods: This study is an observational study conducted on ESRD patients receiving hemodialysis. Patients with active infectious disease, liver disease, and coronary artery disease with stent were excluded. CAC score was measured by non-enhanced computed tomography. And before starting hemodialysis, PIVKA-II, osteocalcin (OC), bone-specific alkaline phosphatase (BAP)were collected. PIVKA-II was measured two times with 3 months interval, and the average value was calculated. Results: Among 69 hemodialysis patients, 34 patients had diabetes mellitus (DM). Patients with DM had higher Body Mass Index (BMI) (p=0.01) and a higher frequency of vascular diseases such as coronary artery disease or cerebrovascular disease (p=0.004). The DM group also had higher LDL cholesterol levels (p=0.03), but there was no significant difference between the two groups in terms of PIVKA-II, BAP, and Osteocalcin levels (Table1). When analyzing the factors that had a correlation with the CAC score, LDL cholesterol (r=-0.37, p=0.002) and CRP (r=0.28, p=0.03) were found to have a significant correlation, but PIVKA-II (p=0.065, Figure 1A), BAP (p=0.57), and OC (p=0.45) did not. In the DM group, there was a significant correlation between CAC score and PIVKA-II (r=0.283, p=0.001, Figure 1B). Conclusions: In patients with diabetes who undergo dialysis, PIVKA-II can be clinically useful as a surrogate marker for predicting CAC associated with vitamin K deficiency. This is because diabetic patients may have more pronounced VKDP inactivation and VC.