Despite lack of evidence from randomized controlled trials (RCTs) about the optimal time to start kidney replacement therapy (KRT), there has been a trend, which has leveled off since 2010, in the United States toward earlier initiation of dialysis at higher levels of kidney function. If earlier dialysis is ineffective, this trend would lead to greater resource utilization without clinical benefit. Published in 2010, results of the IDEAL (Initiating Dialysis Early and Late) trial explored this issue, and data from this trial constitute the best evidence regarding timing of dialysis initiation, motivating the update of this guideline.