The experience with 14 patients with end-stage renal disease (ESRD), 13 of them maintained on chronic hemodialysis (x̄ 20.4 months ± 2.9 SEM) and one following successful renal transplantation, underwent placement of a peritoneovenous shunt (PVS) for refractory ascites that had been present before insertion from two to 15 months (x̄ 5.3 ± 0.8 SEM). A 'specific' cause for the ascites could not be identified in any of the 14 patients. The ascites was an exudate in every patient (protein content > 3.5 gm/dl). Twelve patients (86%) obtained significant relief of the discomfort and all effects of the ascites, and objective clinical improvement persisted for at least six months. Nine patients (75%) survived one year and six (50%) survived three or more years. Three patients (21%) had recurrence of ascites because of shunt malfunction; however, two of them were successfully treated with placement of a second shunt. Eight (57%) patients have died since the onset of their ascites (x̄ 14.1 months ± 3.5 SEM); one death was attributable to PVS placement, while the other seven deaths were due to complications of their ESRD. Insertion of a PVS is an effective therapeutic alternative to palliate the discomfort and ill effects of massive nephrogenic ascites that is often refractory to hemodialysis with ultrafiltration.