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This review is part of the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) report on Europe and Central Asia (ECA) and provides a critical assessment of issues facing decision-makers, including freshwater biodiversity and ecosystem trends as well as drivers of change. Freshwater systems are well established as the most threatened ecosystem type in the ECA region, with the quantity and quality of habitats and abundance of many species rapidly declining. Only about half (53%) of the EU's rivers and lakes achieved good ecological status in 2015 (as defined by the Water Framework Directive in terms of the quality of the biological community), and many lakes, ponds, and streams are disappearing as a consequence of agricultural intensification and inefficient irrigation and urbanisation, combined with climate change. The situation regarding freshwater biodiversity remains highly critical in ECA as many species remain threatened with extinction, including >50% of known species for some groups (e.g., molluscs, amphibians). Drivers of ECA freshwater taxa include the destruction or modification of their habitat, including water abstraction, which affects ∼89% of all amphibian threatened species and ∼26% of threatened freshwater invertebrate species. Of particular concern is the lack of data for freshwater invertebrates. Current status is available for only a minority of species, and the impact of alien invasive species is often unknown, especially in Central Asia. Based on current freshwater biodiversity trends, it is highly unlikely that ECA will achieve either the respective Aichi biodiversity targets by 2020 (i.e., targets 2 to 4, 6 to 12, and 14) or Target 1 of the Biodiversity Strategy.