Background: Patients with end stage renal disease (ESRD) are at high risk for peripheral artery disease (PAD). We sought to determine the national prevalence of PAD, trends in management and outcomes among this high risk population. Methods: We queried the 2003-2014 National Inpatient Sample databases to identify PAD related admissions (claudication and critical limb ischemia) among patients with ESRD using ICD-9 codes. Temporal trends in treatment options, and in-hospital mortality were analyzed. Multivariate logistic regression was used to assess predictors of major amputation. Results: Among 9 million ESRD patient admissions, 357,949 (3.9%) had PAD related diagnosis. Patients were mainly white (39%), men (58%), with mean age of 65.6 years. The prevalence of PAD slightly decreased from 4.3% in 2003 to 3.9% in 2014 (P trend < 0.001). Utilization of percutaneous transluminal angioplasty (PTA) increased by 142% (10.6% to 25.7%), whereas, open bypass use decreased by 51% (14.1% to 6.9%) during the study period (P trend < 0.001). Moreover, the total number of major amputations was 65,669. There was a notable decline in its usage from 25.9% to 15.3% (adjusted odds ratio [OR] per year: 0.96; 95% confidence interval: 0.95-0.98, P<0.001). Revascularization appeared to reduce the risk of amputation (OR 0.49, P<0.001). On the contrary, hypertension (OR 2.5, P<0.001), heart failure (OR 1.5, P<0.001), and black race (OR 1.5, P<0.001) were independent predictors of amputation. Overall in-hospital mortality rate was 6.3%, with no statistically significant trend throughout the years. Conclusion: PAD is a common disease in ESRD patients. Among therapeutic options, a significant increase in less invasive endovascular revascularization methods and a decline in open bypass surgeries were noted. Despite the significant drop in amputation rates, racial disparities persist, with black patients having higher odds of major amputation.