End-stage renal disease (ESRD) affects approximately 745,000 individuals in the United States. Patients with ESRD are dependent on renal replacement therapy (RRT) via dialysis or kidney transplantation. The two dialysis modalities are peritoneal dialysis and hemodialysis. No differences in long-term mortality rates between the two modalities have been shown. Peritoneal dialysis is performed at home. Hemodialysis typically is performed at a dialysis center through vascular access via an arteriovenous fistula (which must mature for several months before use), an arteriovenous graft (which can be used in as few as 24 hours, depending on the graft material), or a central venous catheter (usable immediately but associated with the highest risk of infection). Transplantation is the treatment of choice for patients with ESRD, and referral should be offered to patients who are candidates. However, some patients with ESRD decide against RRT and opt for supportive care. For these patients, and for patients who choose to discontinue dialysis, palliative care and hospice referral are indicated. For all patients with advanced chronic kidney disease or ESRD, treatment includes management of complications, including hyperkalemia, hypervolemia, metabolic acidosis, anemia, mineral and bone disorders, and protein-calorie malnutrition.