Objective <p>To compare survival differences between hemodialysis (HD) and peritoneal dialysis (PD) in elderly patients (≥ 60 years old) with end-stage renal disease (ESRD), and to analyze the impact of key comorbidities (heart failure, cerebrovascular disease, diabetes) on prognosis and causes of death, to inform dialysis modality selection.</p> Methods <p>This single-center retrospective cohort study enrolled 377 elderly ESRD patients (216 HD, 161 PD) who initiated dialysis between 2012 and 2017, with follow-up until 2024. Survival rates were compared using the Kaplan-Meier method. The Cox proportional hazards model was used to analyze risk factors for all-cause mortality, and the competing risks model was employed to assess risks for specific causes of death. Subgroup analyses were performed for patients with heart failure, cerebrovascular disease, and diabetes.</p> Results <p>In the overall population, the HD group had a significantly lower risk of all-cause mortality than the PD group (adjusted HR = 0.599, 95% CI: 0.45–0.79). Subgroup analyses revealed that the survival advantage of HD was particularly pronounced in patients with concomitant heart failure (adjusted HR = 0.422, 95% CI: 0.25–0.70) or diabetes (adjusted HR = 0.687, 95% CI: 0.48–0.98). Notably, HD was identified as an independent risk factor for hemorrhagic death (sHR = 8.773, 95% CI: 1.03–74.42), with the PD group demonstrating a markedly lower cumulative incidence of such events.</p> Conclusion <p>For elderly ESRD patients, dialysis modality selection should be individualized based on comorbidities. HD may be associated with a survival benefit and might be prioritized for patients with concomitant heart failure or diabetes. PD may be considered a safer option, particularly for patients with cerebrovascular disease who are at high risk of bleeding.</p> Clinical trial number <p>Not applicable.</p>