High-solid anaerobic digestion (HS-AD) has been applied extensively during the last few decades for treating various organic wastes, such as agricultural wastes, organic fractions of municipal solid wastes, and kitchen wastes. However, the application of HS-AD to the processing of sewage sludge (SS) remains limited, which is largely attributable to its poor process stability and performance. Extensive research has been conducted to attempt to surmount these limitations. In this review, the main factors affecting process stability and performance in the HS-AD of SS are comprehensively reviewed, and the improved methods in current use, such as HS sludge pre-treatment and anaerobic co-digestion with other organic wastes, are summarised. Besides, this paper also discusses the characteristics of substance transformation in the HS-AD of SS with and without thermal pre-treatment. Research has shown that the HS effect is due to the presence of high concentrations of substances that may inhibit the function of anaerobic microorganisms, and that it also results in poor mass transfer, a low diffusion coefficient, and high viscosity. Finally, knowledge gaps in the current research on HS-AD of SS are identified. Based on these, it proposes that future efforts should be devoted to standardising the definition of HS sludge, revealing the law of migration and transformation of pollutants, describing the metabolic pathways by which specific substances are degraded, and establishing accurate mathematical models. Moreover, developing green sludge dewatering agents, obtaining high value-added products, and revealing effects of the above two on HS-AD of SS can also be considered in future.