The discovery of anaerobic ammonium oxidation (anammox) has greatly improved the understanding of the nitrogen cycle. Anammox provides great promise for the removal of nitrogen from wastewater, containing high concentration of ammonium. However, the presence of organic carbon is considered as unfavorable to this autotrophic process, i.e. anammox. Most of the real wastewaters contain both organic carbon and nitrogen. Under this circumstance, several processes have been established primarily for the complete removal of organic carbon. Subsequently, the wastewater containing no or low organic carbon and nitrogen is treated via a variety of nitrogen removal processes. The co-existence of anammox and denitrification could be useful for the simultaneous removal of nitrogen and organic carbon in a single system rather than a sequential chain of treatment. This review addresses the microbiology, strategies, consequences and the future research challenges in the co-existence of anammox and denitrification. (C) 2010 Elsevier B.V. All rights reserved.