Vancomycin has been a cornerstone antibiotic for the treatment of severe gram-positive infections in dialysis patients for decades. Whereas subtherapeutic vancomycin levels convey a risk of treatment failure and the further emergence of resistance in staphylococci, supratherapeutic vancomycin levels are associated with a dose-related incremental risk for nephrotoxicity and ototoxicity. Consequently, a narrow therapeutic range with a trough-level target between 15 and 20 μg/ml is recommended. Vancomycin dosing in hemodialysis patients is mainly influenced by the timing of administration (during or after dialysis), the type of filter used, and the duration of dialysis. Actual body weight, the interdialytic interval, and residual renal function are also considerations. As in patients with normal kidney function, a weight-based loading dose of 20–25 mg/kg should be used in dialysis patients. While most fixed-dose maintenance regimens fail to reach target levels in the majority of hemodialysis patients, straightforward evidence on optimal maintenance dosing is lacking.