Over the past decade a trend of increasing estimated glomerular filtration rate (eGFR) at the initiation of dialysis for treatment of end-stage renal disease (ESRD) has been noted in the United States. In 1996, only 19% of patients began dialysis therapy with an eGFR of greater than 10 ml/min/1.73 m2 (denoted as 'early start'), but by 2005 the fraction of early start dialysis patients had risen to 45%. This review examines US dialysis data, national guidelines, and publications relevant to the early start phenomenon. It is not known whether early start of dialysis is beneficial, harmful or neutral with respect to the outcome of dialysis treatment for ESRD. Available data indicate that mortality while on dialysis therapy may be higher in those subjects with early start. Comorbidities present at the time of dialysis initiation do not appear to be a major driving force for early start patients. As well, residual kidney function in these patients is a major contributor to total urea or creatinine clearance. This can be a positive factor for patient outcomes and might be compromised by early start. Finally, we estimate the dollar cost of early start to the US Medicare-supported ESRD program. Properly designed, prospective and randomized studies may help to clarify the benefit or harm of early start of dialysis for ESRD.