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The integration of anaerobic treatment technologies using the anammox process could be a sustainable wastewater treatment option for the removal of carbon and nitrogen. This review summarizes the possible limiting factors and the prospects of overcoming them for the successful application of anammox in the mainstream anaerobic treatment of municipal wastewater at low temperatures. Potential areas for mainstream application of anammox covered in this review include integrated nitrogen removal processes with anammox to deal with nitrate production, process engineering of operational parameters to address the effect of organic carbon, low temperature, and nitrite competition. In addition, this review also discusses the emerging issues of micro pollutant removal using the anammox process. The main conclusions of this review are (1) integration of anammox with other autotrophic denitrification processes can help to reduce effluent nitrate concentrations. (2) Access limitation of nitrite oxidizing bacteria (NOB) to dissolved oxygen (DO) in the form of step aeration can be possible approaches to win the competition over nitrite. (3) Demonstration of anammox treatment of municipal anaerobic effluents under real treatment conditions at low temperature and more understanding of complex interactions of anammox with anaerobic effluent should be addressed in the future. [ABSTRACT FROM AUTHOR]