Acute kidney injury (AKI) is now well recognized as an independent risk factor for increased morbidity and mortality, particularly when dialysis is needed. The wide variation in dialysis utilization contributes to a lack of consensus on what parameters should guide the decision to start dialysis. While the association of early initiation of dialysis with survival benefit was first demonstrated four decades ago, few studies in the modern era of dialysis have addressed time of dialysis initiation. Though listed as one of the top priorities in research on AKI, timing of dialysis initiation has not been included as a factor in any of the large, randomized controlled trials in this area.