Objectives: In Singapore, majority of the patients with End Stage Renal Disease (ESRD) who are initiated on renal replacement therapy (RRT) continue to choose hemodialysis (HD) as their preferred option. This study was performed to understand the reasons behind the choice of RRT as a treatment modality. Methods: Single-center retrospective study of patients with a glomerular filtration rate (GFR) ≤ 20ml/min/1.73m2 who received counseling on RRT modalities (April 2021 to April 2022). The primary outcomes include the choice of RRT modality, patient outcomes (initiation of RRT or mortality from ESRD), and the factors influencing the decision-making process. Results: A total of 372 patients (mean 65.7±12.4 years of age; 56.2% male) were studied. Thirty-four patients died before RRT initiation. At time of counselling, 25.4% were undecided, 46.3% opted for HD, 22.8% chose PD, and 2.7% preferred conservative management. Factors influencing decision included personal considerations (45.4%), such as lifestyle disruptions, work-related concerns, and convenience. Family-related reasons (18.8%), encompassing burden to family, absence of caregivers and limited social support. Compared to patients who opted HD, patients who initially preferred PD ended up transitioning to HD (94.2% vs 48.2% P< 0.05). Patient who changed their RRT modality from PD to HD tend to have a higher burden of comorbidities (Charlson scores). Patients who prefer PD has better ambulatory status and independence in Activities of Daily Living (ADL) compared to those who opt for HD. The social economic status (education, housing type and marital status) appear to have minimal influence in patient’s decision of their preferred RRT modality. Conclusions: Despite the nation’s PD-preferred strategy, the study concludes that the choice between HD and PD for RRT is significantly influenced by patient preferences, ADL status, and Charlson score.