Current recommendations for the initiation of dialysis are based on the level of kidney failure and on clinical evidence of uremia. Several nephrology societies advocate the early start of dialysis, i.e., when the glomerular filtration rate (GFR) is higher than or equal to 10 mL/min/1.73 m2, to minimize the clinical and social problems related to advanced uremia. It is not fully known whether the early start of dialysis is beneficial, harmful or neutral with respect to the outcome of dialysis treatment in end stage renal disease. Recent studies have reported no benefit in patient survival from initiating dialysis treatment at a higher GFR. The available data indicate that the mortality while on dialysis may be higher with an early start, and that there is no significant benefit in terms of quality of life. Whether this is explained by a greater comorbidity burden or detrimental effects of early initiation remains unclear. In clinical practice, there is considerable variation in the timing of initiation of maintenance dialysis for patients with end stage renal disease. We support initiating dialysis at a lower GFR (< -7.0 mL/min) provided that patients are given careful clinical management, and at an even lower rate in selected elderly patients given a supplemented very low protein diet. In this group of patients it is possible to initiate dialysis at a very low GFR (< -5 mL/min/1.73 m2) if there is careful management of the nutritional status, fluid and electrolyte balance, body weight, mineral metabolism, anemia, and blood pressure.