Despite improvements in the care of pediatric patients with end-stage kidney disease, children receiving dialysis continue to have unacceptably high mortality, with an average lifespan that is 30 to 40 years shorter compared with individuals matched for age and ethnicity.1,2 Current strategies to improve patient survival include preemptive transplantation and expedited transition from dialysis to transplantation. But what about the children who must have long-term dialysis? What is the best approach to improve long-term outcomes in this population, including the timing of dialysis initiation? If receiving maintenance dialysis even for a few months is associated with increased mortality,2 could delaying dialysis initiation for a few months have a survival benefit for these children?