Background Slow walk (gait) speed predicts functional decline, institutionalization, and mortality risks in the geriatric population. A gait speed evidence base for dialysis patient outcomes is needed. Study Design Prospective cohort study. Setting & Participants 752 prevalent hemodialysis (HD) patients aged 20 to 92 years evaluated in 2009 to 2012 in 7 Atlanta and 7 San Francisco clinics in a US Renal Data System special study. Predictor Usual walk speed in meters per second, categorized as ≥0.6 m/s (baseline n = 575), <0.6 m/s (baseline n = 94), and unable to perform walk test (baseline n = 83). Outcomes Survival; hospitalization; activities of daily living (ADL) difficulty; 36-Item Short Form Health Survey (SF-36) Physical Function score. Measurements Cox proportional hazards models investigated gait speed and mortality over a median follow-up of 703 days. Multivariable logistic or linear regression models estimated associations of baseline gait speed with hospitalization, need for ADL assistance, and SF-36 Physical Function score after 12 months. Results Participants who walked ≥0.6 m/s had 53 (9%) deaths, those who walked <0.6 m/s had 19 (20%) deaths, and those unable to walk had 37 (44%) deaths. Adjusted mortality hazard ratios were 2.17 (95% CI, 1.19-3.98) for participants who walked <0.6 m/s and 6.93 (95% CI, 4.01-11.96) for those unable to walk, compared with participants walking ≥0.6 m/s. After 12 months, compared with baseline walk speed ≥ 1.0 m/s (n = 169 participants), baseline walk speed of 0.6 to <0.8 m/s (n = 116) was associated with increased odds of hospitalization (OR, 2.04; 95% CI, 1.19-3.49) and ADL difficulty (OR, 3.88; 95% CI, 1.46-10.33) and a −8.20 (95% CI, −13.57 to −2.82) estimated change in SF-36 Physical Function score. Limitations Cohort not highly representative of overall US in-center HD population. Conclusions Because walking challenges the heart, lungs, and circulatory, nervous, and musculoskeletal systems, gait speed provides an informative marker of health status. The association of gait speed with HD patients’ risk for functional decline warrants continued study.