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The association between body fat and mortality in hemodialysis patients remains controversial. We examined the effect of percent body fat (PBF) on all-cause mortality among adequate hemodialysis patients with and without insulin resistance (IR). A prospective cohort study was conducted on 365 adequate hemodialysis patients (equilibrated Kt/V &#8805; 1.2) from seven hospitals. Patients&#8217; characteristics and clinical and biochemical parameters were assessed at baseline between September 2013 and April 2017. Patients were followed up for all-cause mortality until April 2018. The median value of homeostatic model assessment (HOMA-IR) was used to classify IR. Cox proportional hazard models were utilized to examine predictors of all-cause mortality. During 1.4 (1.0&#8722;3.2) years of follow-up, 46 patients died. In patients with IR (HOMA-IR &#8805; 5.18), PBF was significantly higher in the survival group than in the death group (31.3 &#177; 9.0 vs. 25.4 &#177; 8.2, <i>p</i> = 0.005). After controlling for confounding factors, PBF was significantly associated with lower risk for all-cause mortality in patients with IR (hazard ratio, 0.94; 95% confidence interval, 0.89&#8722;1.00; <i>p</i> = 0.033). The association was not observed in patients without IR. In conclusion, percent body fat shows a protective effect on survival in hemodialysis patients with IR.