The cirrhotic patient with ascites presents unique challenges to the renal caregiver. This patient population has relative contraindications both to hemodialysis (HD) and to peritoneal dialysis (PD). Challenging hemodynamics and the bleeding risk from acquired coagulopathy make HD problematic. In PD, tense ascites can increase the risk of early catheter leak and complicate the initial instillation of dialysate. These patients are at increased risk of spontaneous bacterial peritonitis and would be suspected to have peritonitis rates different from those in non-cirrhotic patients. Ongoing protein losses in the dialysate may aggravate underlying malnutrition. Despite these concerns, available clinical reports suggest that patients with cirrhosis can be successfully managed on PD. The present review focuses on the application of PD therapy in the cirrhotic patient with ascites. Technical aspects of initiating PD are reviewed, and clinical reports, peritonitis risk, and infection control strategies are discussed. Dialysate increases intra-abdominal pressure and may oppose the formation of ascites; the impact of these mechanics on dialysate protein losses and portal hemodynamics are reviewed.