Wastewater management has experienced different stages, including pollutant removal, resource recovery, and water nexus. Within these stages, anaerobic ammonia oxidation-based biotechnology can be incorporated for nitrogen removal, which can help achieve sustainable wastewater management, such as reclamation and ecologization of wastewater. Here, the physiology, metabolism, reaction kinetics and microbial interactions of anammox bacteria are discussed, and strategies to start-up the anammox system are presented. Anammox bacteria are slow growers with a high doubling time and a low reaction rate. Although most anammox bacteria grow autotrophically, some types can grow mixotrophically. The reaction stoichiometric coefficients can be affected by loading rates and other biological reactions. Microbial interactions also contribute to enhanced biological nitrogen removal and promote activities of anammox bacteria. The start-up of the anammox process is the key aspect for its practical application, which can be realized through seed selection, system stimulation, and biomass concentration enhancement.