Many older patients with advanced CKD approaching ESRD do not receive timely nephrology care, although data suggest that the situation may be improving. In 2005–2008, 43% of older patients who initiated renal replacement therapy had experienced an outpatient nephrologist consultation more than 1 year before starting treatment. Earlier consultation with a nephrologist has been found to provide better access to peritoneal dialysis and kidney transplantation, better preparation for the chosen dialytic modality, and improved survival after start of dialysis or receipt of a kidney transplant. Recent data suggest that older individuals are less likely to receive treatment for ESRD compared with younger individuals in whom almost all receive dialysis treatment or transplantation. Little is known about the role nephrologists play in the decision whether to initiate dialysis or choose a conservative route among older adults with ESRD. Defining the appropriate role and involvement of nephrologists in the decision about initiating renal replacement therapy in older adults seems ripe for further investigation and discussion.