Patients with end-stage renal disease (ESRD) experience significant morbidity and mortality. Despite improvements in mortality rates, the life expectancies for dialysis patients are still between 16 and 37% of the age-, gender-, and race-matched U.S. population. One of the factors that thus far has received scant attention, but could significantly contribute to morbidity and mortality among ESRD patients, is the timing and quality of care before initiation of dialysis (pre-ESRD care). Pre-ESRD care involves early detection of progressive renal disease, interventions to retard its progression, prevention of uremic complications, attenuation of comorbid conditions, adequate preparation for renal replacement therapy (RRT), and timely initiation of dialysis. Despite the benefits of pre-ESRD care, recent studies suggest that the quality of pre-ESRD care in the United States is suboptimal. However, indices of quality of pre-ESRD care have been neither clearly defined nor validated. Furthermore, few estimates of the size of the pre-ESRD population are available. This review examines the prevalence of several factors that could reasonably be used to define suboptimal pre-ESRD care, including failure of early detection of renal disease, paucity of interventions to slow its progression, predialysis hypoalbuminemia and severe anemia, suboptimal pre-ESRD education and uninformed choice of modality of RRT, delayed placement of a permanent vascular access, and delayed initiation of RRT. Although the data presented strongly suggest that the quality of pre-ESRD care in the United States is suboptimal, further research is needed for a better definition and validation of indices of quality pre-ESRD care, a more accurate estimate of the size of the pre-ESRD population, examination of the causes of suboptimal pre-ESRD care, and identification of populations at risk for suboptimal pre-ESRD care. This understanding would facilitate development of strategies to improve pre-ESRD care and, eventually, outcomes among patients on RRT.