Most dialysis patients have coronary artery disease at the initiation of dialysis therapy and these patients also have marked vascular calcification. Virtual histology–intravascular ultrasound (VH–IVUS) provides coronary tissue maps that are color coded by four major plaque components and facilitate the characterization of coronary plaque composition in vivo. The aim of this study was to identify coronary plaque characteristics in dialysis patients using VH–IVUS. Twenty-three patients with coronary artery disease were included in this study. Of these, 12 patients had normal renal function or mild renal insufficiency (control group) and 11 patients were receiving maintenance dialysis therapy (hemodialysis group). We performed coronary angiography and VH–IVUS analysis on culprit lesions of all patients in the study. The result of VH–IVUS analysis showed that the hemodialysis group had a greater plaque volume, lower percentage of fibrous plaque, and higher percentage of dense calcium plaque compared with the control group. In addition, the serum phosphate levels were significantly associated with the percentage of necrotic core and dense calcium plaque in all study patients. Our findings suggest that the amount of necrotic core and dense calcium plaques increase significantly in hemodialysis patients, and that disordered mineral metabolism may be associated with coronary plaque morphology.