Hemodialysis (HD) is often used as an example of the most expensive chronic medical intervention that society will pay for on an ongoing basis. More intensive forms of HD have been associated with improved clinical outcomes, but concerns have been raised regarding the possibility of increased costs. We review recent Canadian studies examining the costs and cost utility of intensive HD, with a focus on comparisons with conventional in-center hemodialysis (IHD). The costs of starting a new home nocturnal hemodialysis (HNHD) program in British Columbia was estimated to be about $510,000 for the first year of the program, including the training of the first 53 patients, or about $18,830 per patient. A study by Lee et al. found the costs of home HD to be substantially less than IHD ($93,976 vs. $54,936, p < 0.001). A study by Kroeker et al. found that the lowest costs were seen with home short daily HD ($82,522), compared with $89,154 for IHD, and $91,218 for HNHD. Two studies by McFarlane et al. found that total costs were lower for those receiving HNHD (IHD $87,172 vs. HNHD $71,313), and that HNHD was associated with a superior cost-utility ratio (CAN$ 2011, HNHD $84,430/quality-adjusted life year [QALY] vs. IHD $148,722/QALY, incremental cost-effectiveness ratio: −$54,281, p < 0.05). While consistent findings of lower staffing and overhead costs for home HD, and higher consumable costs for frequent dialysis are probably reliable, findings of lower medication and hospital admission costs seen with intensive HD will need confirmation in randomized studies. Modifications to conventional dialysis funding are needed to accommodate for the additional costs of supplies and technology needed to support intensive modalities.