Hemodialysis remains the principal form of renal replacement therapy worldwide, and increasing numbers of patients have survived for 20 years or more. Future issues include the incorporation of newer technology into dialysis programs, ensuring adequacy of dialysis and optimum quality of care, controlling hypertension, and ensuring adequate nutrition. To maximize survival, hypertension must be controlled from its onset, smoking must be stopped, adequate dialysis provided, normal nutrition maintained, and blood access preserved. Home hemodialysis provides the best quality of life and opportunity for rehabilitation, but opportunities for this treatment may be limited. The long-term care of patients with end-stage renal disease requires careful attention to all aspects of their treatment on an ongoing basis, potentially for many years.