In contrast to outpatient dialysis facilities in the United States, which are required by the Centers for Medicare & Medicaid Services (CMS) under the Conditions for Coverage for ESRD Facilities to have a qualified medical director who oversees facility quality and operations,1-3 inpatient dialysis programs have no such requirement. Despite the high level of complexity of inpatient dialysis therapies, currently there is no CMS or other governing body regulation that describes the qualifications and responsibilities for physician leadership oversight for kidney replacement therapy (KRT) performed in hospitalized patients.