As the End-stage renal disease population continues to grow, innovative strategies that optimize patient outcomes while capitalizing on the relative strengths of the existing modalities must be sought. Renal transplantation remains the preferred form of renal replacement therapy, but given the limited supply of donor organs, dialytic therapies will continue to constitute a large part of the modality mix. Matching patients to the most suitable modalities requires that a number of factors be considered. These include the patient's autonomy, medical and social factors, system-related issues, patient outcomes, and finances. While peritoneal dialysis and hemodialysis (HD) have traditionally been viewed as competing modalities, we propose that they, along with home and frequent HD regimens, may be used in a complementary manner, which is based on current evidence, and may provide optimal outcomes while containing treatment costs. In this review, we attempt to synthesize the current literature describing the various issues that affect modality selection, and offer an approach to achieving a balance between these many competing factors.