Dry Weight Reduction Intervention Via Extra Ultrafiltration

Inclusion Criteria:

* Receiving thrice weekly in-center hemodialysis treatments for end stage kidney disease for at least four weeks and clinical suspicion of volume excess based on either:

  1. Persistent hypertension defined by three consecutive pre-dialysis systolic blood pressures ≥140 mmHg or three consecutive pre-dialysis systolic blood pressures 130-140 mmHg plus use of at least two anti-hypertensive medications that can be tapered.

     OR
  2. Symptoms of congestion defined by a 12-item Kidney Modified Kansas City Cardiomyopathy Questionnaire (KM-KCCQ) score \<75.

     Exclusion Criteria:
* Age \<18 years
* Receiving hemodialysis treatments for acute kidney injury
* Receiving hemodialysis treatments for less than four weeks
* Planned switch to peritoneal or home dialysis within next three months
* Current or planned incremental hemodialysis (less than 3 treatments per week)
* Current or planned intensive hemodialysis (four or more treatments per week)
* Scheduled kidney transplantation
* Major cardiovascular or bleeding event within previous 90 days
* Receiving chemotherapy or radiation treatment for cancer
* History of cirrhosis with ascites
* Inability to complete 24-hour ambulatory blood pressure measurement
* Wheelchair dependance or other inability to complete six-minute walk test
* Pre-dialysis systolic blood pressure \<100 mmHg
* Scheduled use of midodrine with hemodialysis treatments
* History of non-adherence with dialysis treatments
* Pregnancy
* Institutionalized
* Current or pending enrollment in hospice care
* Inappropriate for enrollment based on investigator or nephrologist discretion