When hemodialysis (HD) was introduced as an effective workable treatment in 1943,1 the outlook for patients with advancing kidney failure suddenly changed from anticipation of impending death to indefinite survival. Since then, implementation of dialysis has advanced from an intensive bedside therapy to a more streamlined treatment, sometimes self-administered in the patient’s home, using modern technology that has simplified dialysis treatment by reducing the time and effort required by the patient and caregivers. Standards have been established to efficiently care for large numbers of patients with a balance of resources and patient time. However, simplified standards can lead to inadequate treatment, so guidelines have been developed to assure patients, caregivers, and financial providers that reversal of the uremic state is the best that can be offered and complications are minimized. The National Kidney Foundation (NKF) continues to sponsor this forum for collaborative decision making regarding the aspects of HD that are considered vital to achieve these goals. Over 400,000 patients are currently treated with HD in the United States, with Medicare spending approaching $90,000 per patient per year of care in 2012.2 Unfortunately, although mortality rates are improving (30% decline since 1999), they remain several-fold higher than those of age-matched in-dividuals in the general population, and patients experience an average of nearly 2 hospital admissions per year.3 Interventions that can improve outcomes in dialysis are urgently needed. Attempts to improve outcomes have included initiating dialysis at higher glomerular filtration rates (GFRs), increasing dialysis frequency and/or duration, using newer membranes, and employing supplemental or alternative hemofil-tration. Efforts to increase the dose of dialysis admin-istered 3 times weekly have not improved survival, indicating that something else needs to be addressed