Controlling the spread of hepatitis B virus (HBV) infection in dialysis units has been one of major triumphs in the management of end-stage renal disease. However, HBV incidence and prevalence rates remain high in dialysis patients in less-developed countries, and HBV within dialysis units continues to spread in the industrialized world. Overall response rates to HBV vaccination are lower in dialysis patients than in the nondialysis population. Lamivudine is effective in the treatment of HBV infection in the dialysis setting. Presence of hepatitis B surface antigen (HbsAg) has a negative impact on patient survival after renal transplantation. Several issues remain unanswered with regard to the management of HBV infection in dialysis patients, including the management of lamivudine resistance and the optimal timing and duration of antiviral therapy. Liver biopsy prior to renal transplantation is crucial in order to identify and exclude patients with advanced fibrosis or even cirrhosis.