Surface freshwaters -- lakes, reservoirs, and rivers -- are among the most extensively altered ecosystems on Earth. Transformations include changes in the morphology of rivers and lakes, hydrology, biogeochemistry of nutrients and toxic substances, ecosystem metabolism and the storage of carbon (C), loss of native species, expansion of invasive species, and disease emergence. Drivers are climate change, hydrologic flow modification, land-use change, chemical inputs, aquatic invasive species, and harvest. Drivers and responses interact, and their relationships must be disentangled to understand the causes and consequences of change as well as the correctives for adverse change in any given watershed. Beyond its importance in terms of drinking water, freshwater supports human well-being in many ways related to food and fiber production, hydration of other ecosystems used by humans, dilution and degradation of pollutants, and cultural values. A natural capital framework can be used to assess freshwater ecosystem services, competing uses for freshwaters, and the processes that underpin the long-term maintenance of freshwaters. Upper limits for human consumption of freshwaters have been proposed, and consumptive use may approach these limits by the mid-century.