Most dialysis patients would choose to receive a kidney transplant if possible. However, some patients who are receiving intensive hemodialysis (HD) have opted against transplantation and have chosen to remain on dialysis. In this paper, we examine studies that help to inform the decision between receiving a kidney transplant and remaining on intensive HD. There are no randomized trials directly comparing transplant to intensive HD. Database and prospective nonrandomized studies support a number of conclusions. First, compared to conventional HD, survival appears to be better with either transplantation or intensive HD. Survival appears to be similar between intensive HD and deceased donor kidney transplantation, but the best survival is reported with live donor transplantation. Secondly, people with a kidney transplant or receiving intensive HD report a higher quality of life than people on conventional HD. There is insufficient evidence to determine whether there are significant quality of life differences between these treatments. Finally, the costs of intensive HD compare favorably to those of conventional HD. Renal transplantation is more costly in the first year, but after about 2 years should be less costly than any form of HD. Based on these studies eligible intensive HD patients should be encouraged to pursue transplantation, especially live kidney donor transplantation. Individual concerns about the relative risks and benefits of renal transplantation may drive some patients to choose to stay on dialysis. Clinicians should explore the reasons behind such a decision to ensure that the patient is properly informed; however, appropriately reasoned decisions should be respected.