Background: The optimal timing for initiating dialysis in end-stage renal disease (ESRD) remains controversial, especially in elderly patients. We therefore investigated the effect of dialysis initiation timing on clinical outcomes in elderly patients with ESRD. Method: A total of 665 patients aged equal or over 65 years who started dialysis from August 2008 to February 2015 were enrolled in Clinical Research Center for End Stage Renal Disease cohort study in Korea. They were divided into 2 groups based on the median estimated glomerular filtration rate, which was 8.85 mL/min/1.73m2. The primary outcome was patient survival and the secondary outcomes were cardiovascular events and Kidney Disease Quality of Life Short Form 36 (KDQOL-36) score. Results: Overall cumulative survival rates were lower in early initiation group (Log-rank p<0.001). However, the survival rates showed no significant difference after matching propensity score. Additionally, early initiation of dialysis was not associated with survival rates after adjustment for age, sex, Charlson comorbidity index, hemoglobin, serum albumin, serum calcium and phosphorus level. Although the early initiation group showed lower physical component summary in KDQOL-36 at 3 months after dialysis, the difference of the scores was not significant at 12 months after dialysis. Conclusion: Early initiation of dialysis was not associated with prognosis in elderly patients with ESRD. The physical functioning was worse for 3 months after dialysis but it became similar to late initiation of dialysis at 1 year after dialysis.