The percentage of the population in low-middle-income countries (LMIC) with hemodialysis availability has gradually increased over the last 8 years. Note that only 3% of the treatments of these countries are done as peritoneal dialysis, which is the more cost-effective modality. The best current estimate of hemodialysis access for Africa is 25%, Southeast Asia 35%, and South America 65% [1]. The main issues that impede hemodialysis access remain poverty, the unaffordability of treatment, the substantial cost of setting up a dialysis unit as well as the lack of options to purchase dialyzers, tubing, and unit supplies at reasonable costs. This article presents cost-saving approaches for providing hemodialysis in LMIC along with words of caution on how to determine the sustainability of the project in areas with high levels of need and limited resources.