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Background: There is no consensus on the choice of aortic valve prosthesis for patients with end-stage renal failure. We analyzed short- and long-term complications in dialysis patients who underwent aortic valve replacement (AVR) with either a biological (bAVR) or a mechanical (mAVR) prosthesis., Methods: All patients on dialysis who underwent bAVR or mAVR in Sweden from 1995 to 2017 (n=335) were included in a nationwide, population-based, observational, cohort study. Short and long-term complications were compared. Long-term mortality was compared with multivariable Cox regression analysis adjusted for age, sex, comorbidities, and a propensity score-matched model. Median follow-up was 2.8 (range, 0-16) years., Results: Biological and mechanical valves were implanted in 253 (75.5%) and 82 (24.5%) patients, respectively. The bAVR patients were older and had more comorbidities. There was no significant difference in early complication rate. Thirty-day mortality was 9.1% in bAVR and 7.3% in mAVR patients (P=0.62). The multivariable Cox regression model did not show significant difference in mortality risk between bAVR and mAVR patients [adjusted hazard ratio (aHR) 1.33; 95% CI: 0.84-2.13; P=0.22]. The results were confirmed in the propensity-score matched model. The rate of aortic valve reoperations did not differ significantly between the bAVR and mAVR group., Conclusions: The short- and long-term complication rate is high, and the expected life expectancy limited, in dialysis patients undergoing AVR, without significant difference between biological and mechanical prostheses. The results suggest that biological valve prosthesis, avoiding systemic anticoagulation, is appropriate in most dialysis patients., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-21-1410/coif). AJ reports personal fees from Boehringer-Ingelheim, Werfen, Alexion, Baxter, and LFB Biomedicaments, research grants from Swedish state, Swedish Heart Lung Foundation, Västra Götaland Region and Winberg Foundation, and he was a member of the Clinical Guideline Committee for the European Association for Cardiothoracic Surgery, outside the submitted work. ECH reports personal fees from AstraZeneca and Boehringer-Ingelheim, outside the submitted work. The other authors have no conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)