Purpose. The clinical implications regarding the use of statins in patients with end-stage renal disease (ESRD) undergoing hemodialysis are explored. Summary. The majority of the evidence reviewed from randomized controlled trials and recent meta-analyses suggest that there is minimal to no benefit of statin therapy for reducing the risk of coronary heart disease (CHD), including cardiovascular events and mortality, for statin-naive patients undergoing hemodialysis. The Kidney Disease Outcomes Quality Initiative (KDOQI) 2003 dyslipidemia guidelines recommended that patients with ESRD receive a statin to reach a goal low-density-lipoprotein (LDL) cholesterol concentration of <100 mg/dL; however, there was no distinction between nondialysis and dialysis patients, and newer evidence has since been published. Although KDOQI released 2012 guidelines that recommended against the initiation of statins in dialysis patients due to the lack of evidence to support benefit, the guidelines were specific for diabetic dialysis patients. Clinicians should use their clinical judgment and weigh the risks and benefits from the available evidence when deciding whether to initiate statins in hemodialysis patients. A statin may be warranted for secondary prevention of cardiovascular events or in younger hemodialysis patients who have a longer life expectancy. Conclusion. The available literature does not support the initiation of statins in hemodialysis patients who were not receiving statin therapy before requiring hemodialysis. At this time, there are no conclusive data to support discontinuation of statins in ESRD patients on hemodialysis receiving statins for either primary or secondary prevention of CHD.