OBJECTIVES: Despite technological advances in treatment modalities for end stage renal disease (ESRD) the disease continues to impose significant economic and social burdens on patients and health care systems globally. The purpose of this review was to compare the effectiveness of transplantation (Tx) and peritoneal dialysis (PD) to the more common treatment modality, hemodialysis (HD).  The outcome of interest was the health related quality of life (HRQOL) of ESRD patients in the general, physical and psychological domains. METHODS: The primary computerized databases searched for scholarly articles were PubMed and Medline.  Only research studies written in English which met the inclusion criteria were considered.  A random effects model was used to test the hypothesis of equality in mean treatment outcomes.  RESULTS: A total of 21 studies with a combined sample size of 17,099 patients were used in the review.  Patients who received PD did not have a better HRQOL compared to patients receiving HD.  However, the HRQOL of Tx patients was significantly better than that of HD patients in the physical and psychological domains. The overall effect sizes were 0.31, 95 % CI (0.09, 0.53) and 0.29, 95 % CI (0.09, 0.50) respectively, and were statistically significant.    CONCLUSIONS: The findings support the assertion that Tx patients experience significantly better HRQOL than HD patients but only in the physical and psychological domains.  Findings on the effectiveness of PD compared to HD as a treatment modality were inconclusive.