Exercise has been shown to improve sarcopenia outcomes in stable dialysis patients, but there is no clear conclusion in elderly patients with ESRD. This study aimed to evaluate the effects of intradialytic exercise on sarcopenia in elderly patients with ESRD. Studies up until 12 January 2024 were identified from many databases. Keywords used as search terms were “chronic kidney disease”, “dialysis”, “exercise”, “physical function”. Study quality was assessed using the Physiotherapy Evidence Database (PEDro) Scale. A total of 5 RCTs meeting the inclusion criteria were included in this systematic review. Pooled results demonstrated that aerobic training improved the score 6MWT (95%CI [500±30], p<0.001). Resistance training significantly improved the speed of 10MWT (1.45 m/s, 95%CI [1.23 to 1.80 m/s], p<0.001), handgrip strength (21.8 kg, 95%CI [17.5 to 28.0 kg], p<0.05), isometric knee extension strength (43.3%, 95%CI [32.1 to 52.8%], p<0.05), SPPB (12 point, 95%CI [10 to 12 point], p<0.05), 30-s STS (95%CI [9.71±0.42], p<0.01), and 8-foot TUG (95%CI [11.77±3.19], p<0.01). In physical performance, aerobic training and resistance training have some beneficial effect on improving the score 6MWT (95%CI [453.9±96.4], p<0.001; 95%CI [461.0±95.3], p<0.001) and median version of CS-30 (95%CI [15.2±3.7], p<0.001; 95%CI [17.0±4.7], p<0.001). This review showed that resistance training may lead to improvement in muscle strength and muscle mass of elderly patients during dialysis. Combined exercise (aerobic and resistance) may be a potential strategy to improve muscle strength and physical performance in elderly patients with ESRD undergoing dialysis.