Due to their unique advantages like controlled biomass retention, improved effluent quality, and decreased footprint, membrane bioreactors (MBRs) are being increasingly used in waste water treatment up to a capacity of several 100,000 p.e. This article reviews the current status of MBRs and reports trends in MBR design and operation. Typical operational and design parameters are given as well as guidelines for waste water treatment plant revamping. To further improve the biological performance, specific or hybrid process configurations are shown to lead to, e.g., enhanced nutrient removal. With regards to reducing membrane fouling, optimized modules, advanced control, and strategies like the addition of flux enhancers are currently emerging.