We provide an overview of research related to environmental effects of disposal of coal combustion residues (CCR) in sites in the United States. Our focus is on aspects of CCR that have the potential to negatively influence aquatic organisms and the health of aquatic ecosystems. We identify major issues of concern, as well as areas in need of further investigation. Intentional or accidental release of CCR into aquatic systems has generally been associated with deleterious environmental effects. A large number of metals and trace elements are present in CCR, some of which are rapidly accumulated to high concentrations by aquatic organisms. Moreover, a variety of biological responses have been observed in organisms following exposure to and accumulation of CCR-related contaminants. In some vertebrates and invertebrates, CCR exposure has led to numerous histopathological, behavioral, and physiological (reproductive, energetic, and endocrinological) effects. Fish kills and extirpation of some fish species have been associated with CCR release, as have indirect effects on survival and growth of aquatic animals mediated by changes in resource abundance or quality. Recovery of CCR-impacted sites can be extremely slow due to continued cycling of contaminants within the system, even in sites that only received CCR effluents for short periods of time. The literature synthesis reveals important considerations for future investigations of CCR-impacted sites. Many studies have examined biological responses to CCR with respect to Se concentrations and accumulation because of teratogenic and reproductively toxic effects known to be associated with this element. However, the complex mixture of metals and trace elements characteristic of CCR suggests that biological assessments of many CCR-contaminated habitats should examine a variety of inorganic compounds in sediments, water, and tissues before causation can be linked to individual CCR components. Most evaluations of effects of CCR in aquatic environments have focused on lentic systems and the populations of animals occupying them. Much less is known about CCR effects in lotic systems, in which the contaminants may be transported downstream, diluted or concentrated in downstream areas, and accumulated by more transient species. Although some research has examined accumulation and effects of contaminants on terrestrial and avian species that visit CCR-impacted aquatic sites, more extensive research is also needed in this area. Effects in terrestrial or semiaquatic species range from accumulation and maternal transfer of elements to complete recruitment failure, suggesting that CCR effects need to be examined both within and outside of the aquatic habitats into which CCR is released. Requiring special attention are waterfowl and amphibians that use CCR-contaminated sites during specific seasons or life stages and are highly dependent on aquatic habitat quality during those periods. Whether accidentally discharged into natural aquatic systems or present in impoundments that attract wildlife, CCR appears to present significant risks to aquatic and semiaquatic organisms. Effects may be as subtle as changes in physiology or as drastic as extirpation of entire populations. When examined as a whole, research on responses of aquatic organisms to CCR suggests that reducing the use of disposal methods that include an aquatic slurry phase may alleviate some environmental risks associated with the waste products.