Dialysis is the most common therapeutic intervention for patients with end-stage renal disease (ESRD). The demonstration of a clear survival benefit associated with renal transplantation has made it the preferred treatment option for ESRD patients medically cleared for transplant. This has invoked a shift in thinking regarding the timing of transplantation. Impaired renal function and particularly ESRD with dialysis are significant cardiovascular risk factors for this population. Part of these cumulative effects can probably be avoided by transplantation without prior dialysis. In fact, the evidence to date demonstrates a significant advantage for allograft and patient survival associated with preemptive transplantation. In addition, preemptive transplantation is associated with better quality of life for these patients and is less costly than dialysis. The key for patients approaching ESRD is early referral to a transplant center to explore the most appropriate treatment options in a timely fashion. In fact, it is better to transplant patients preemptively than to wait until they reach ESRD and start dialysis.