Increased carotid-femoral pulse wave velocity (cf-PWV) in end-stage renal disease (ESRD) indicates enhanced aortic stiffness and mortality risk. We conducted a systematic review and meta-analysis of nonpharmacologic interventions in adults with ESRD to determine their effects on cf-PWV, systolic blood pressure (SBP), and intervention-associated adverse events.MEDLINE, EMBASE, and EBM databases were searched. Study screening, selection, data collection, and methodological quality assessments were performed by 2 independent reviewers. Pooled-effect estimates from mean differences and 95% confidence intervals (CIs) were calculated using random effect models.A total of 2166 subjects with ESRD from 33 studies (17 randomized; 16 nonrandomized) were included. Four intervention-comparator pairs were meta-analyzed. Quality of evidence ranged from very low to moderate. Kidney transplantation decreased cf-PWV (-0.70 m/s; CI: -1.3 to -0.11;  = 0.02) and SBP (-8.3 mm Hg; CI: -13.2 to -3.3;  < 0.001) over pretransplantation. In randomized trials, control of fluid overload by bio-impedance reduced cf-PWV (-1.90 m/s; CI: -3.3 to -0.5);  = 0.02) and SBP (-4.3 mm Hg; CI: -7.7 to -0.93);  = 0.01) compared with clinical assessment alone. Cross-sectional studies also demonstrated significantly lower cf-PWV and SBP in normovolemia compared with hypervolemia ( ≤ 0.01). Low calcium dialysate decreased cf-PWV (-1.70 m/s; CI: -2.4 to -1.0;  < 0.00001) without affecting SBP (-1.6 mm Hg; CI: -8.9 to 5.8;  = 0.61). Intradialytic exercise compared with no exercise reduced cf-PWV (-1.13 m/s; CI: -2.2 to -0.03;  = 0.04), but not SBP (+0.5 mm Hg; CI: -9.5 to 10.4);  = 0.93).Several nonpharmacologic interventions effectively decrease aortic stiffness in ESRD. The impact of these interventions on cardiovascular outcomes and mortality risk reduction in ESRD requires further study.