Dry Weight Reduction Intervention Via Extra Ultrafiltration

Inclusion Criteria: * Receiving thrice weekly in-center hemodialysis treatments for end stage kidney disease for at least four weeks and clinical suspicion of volume excess based on either: 1. Persistent hypertension defined by three consecutive pre-dialysis systolic blood pressures ≥140 mmHg or three consecutive pre-dialysis systolic blood pressures 130-140 mmHg plus use of at least two anti-hypertensive medications that can be tapered. OR 2. Symptoms of congestion defined by a 12-item Kidney Modified Kansas City Cardiomyopathy Questionnaire (KM-KCCQ) score \<75. Exclusion Criteria: * Age \<18 years * Receiving hemodialysis treatments for acute kidney injury * Receiving hemodialysis treatments for less than four weeks * Planned switch to peritoneal or home dialysis within next three months * Current or planned incremental hemodialysis (less than 3 treatments per week) * Current or planned intensive hemodialysis (four or more treatments per week) * Scheduled kidney transplantation * Major cardiovascular or bleeding event within previous 90 days * Receiving chemotherapy or radiation treatment for cancer * History of cirrhosis with ascites * Inability to complete 24-hour ambulatory blood pressure measurement * Wheelchair dependance or other inability to complete six-minute walk test * Pre-dialysis systolic blood pressure \<100 mmHg * Scheduled use of midodrine with hemodialysis treatments * History of non-adherence with dialysis treatments * Pregnancy * Institutionalized * Current or pending enrollment in hospice care * Inappropriate for enrollment based on investigator or nephrologist discretion