In end-stage renal disease (ESRD) patients, congestive heart failure (CHF) is a dreadful complication. Its pathogenesis is multifactorial. Chronic arterial hypertension, uraemic cardiomyopathy, coronary artery disease (CAD) and valvular disease all lead to myocardial damage that may eventually result in CHF. Other more or less well-proven contributory factors are chronic volume overload, anaemia, metabolic acidosis, secondary hyperparathyroidism, the malnutrition-inflammation complex syndrome and the haemodialysis (HD) arterio-venous fistula (AVF). In the Dialysis Outcomes and Practice Patterns Study (DOPPS), the prevalence of CHF in the HD population was reported to be 46% in the US, but only 25% in Europe and as little as 6% in Japan [1]. Such substantial geographical differences may be explained in part by the fact that the US patients were older and had more diabetes, CAD and other vascular diseases than the European and Japanese patients, but they may also derive from different criteria for defining CHF. As a matter of fact, there is a risk of overdiagnosing CHF in ESRD patients who present with oedema, dyspnoea and enlarged heart, due to extracellular volume expansion. Therefore, a wide consensus on the definition of CHF in this setting is mandatory for a more accurate estimation of the magnitude of this phenomenon. Preventing and treating CHF is a critical task, since nowadays, over 80% of ESRD patients, recently diagnosed with CHF will die within just three years [2]. The topic we wish to debate here is the influence of the initial dialysis modality upon the outcome of patients with ESRD and CHF. In other words, what should we choose for such patients: HD or peritoneal dialysis (PD)? Unfortunately, to answer this dilemma, there is very little evidence to count on. Randomized survival studies are lacking, and for ethical reasons, such studies will probably never be conducted. A single comparative (but still non-randomized) HD vs PD study has been done so far, that specifically addressed the survival of ESRD patients with CHF, namely the one published by Stack et al., in 2003 [3]. Therefore, our discussion also needed to include other studies, comparing the influence of HD and PD upon ‘surrogate’ end points, like CHF risk factors, heart structure and function and risk of developing de novo CHF.