Neurovascular　(NV)　decoupling　is　a　potential　neuropathologic　mechanism　of　cognitive　impairment　in　patients　with　end-stage　renal　disease　(ESRD).　Hemodialysis　improves　cognitive　impairment　at　24　h　post-dialysis,　which　suggests　a　potential　neuroprotective　effect　of　hemodialysis　treatment　on　the　brain.　We　investigated　the　effects　of　hemodialysis　treatment　on　the　reversal　of　NV　decoupling　associated　with　cognitive　improvement.　A　total　of　39　patients　with　ESRD　and　39　healthy　controls　were　enrolled.　All　patients　were　imaged　twice　during　a　dialysis　session:　before　hemodialysis　(T1(pre-dialysis))　and　at　24　h　after　dialysis　(T2(post-dialysis)).　The　healthy　controls　were　imaged　once.　NV　coupling　was　characterized　based　on　correlation　coefficients　between　four　types　of　blood　oxygen　level-dependent　signals　and　cerebral　blood　flow　(CBF).　A　battery　of　neuropsychological　and　blood　tests　was　performed　before　the　imaging.　Patients　with　ESRD　showed　improvements　in　memory　and　executive　function　at　T2(post-dialysis)　compared　with　that　at　T1(pre-dialysis).　At　both　T1(pre-dialysis)　and　T2(post-dialysis),　patients　with　ESRD　had　lower　amplitude　of　low-frequency　fluctuation　(ALFF)-CBF　coupling　than　healthy　controls.　Additionally,　patients　with　ESRD　had　higher　ALFF-CBF　coupling　at　T2(post-dialysis)　than　at　T1(pre-dialysis).　Higher　memory　scores,　higher　hemoglobin　level,　lower　total　plasma　homocysteine　level,　lower　systolic　blood　pressure　variance,　and　lower　ultrafiltration　volume　were　associated　with　higher　ALFF-CBF　coupling　in　patients　with　ESRD　after　a　hemodialysis　session.　These　findings　indicate　that　partial　correction　of　anemia　and　hyperhomocysteinemia,　stable　systolic　blood　pressure,　and　fluid　restriction　may　be　closely　linked　to　the　reversal　of　NV　decoupling　and　improvement　in　cognition　in　patients　with　ESRD.