Treatment of end stage renal disease (ESRD) by dialysis or renal transplantation has been available for 20 years. This article considers four issues in the management of ESRD services in the UK. First, there remains inadequate evidence on which treatment is best for which patient. Second, the recent increase in continuous ambulatory peritoneal dialysis may not be a cost-effective choice. Third, both dialysis and transplant centres appear to have substantial opportunities to improve efficiency. Last, the present level of treatment in the UK appears to be meeting needs: other health problems may now have higher priority for health care resources.