This article first describes the epidemiology and reasons of late referal to the nephrologist of patients suffering from end-stage renal disease (ESRD). Depending on the definition, between 25 and 50% of worldwide ESRD patients are referred very late. Second, the relation of late referral to the quality of pre-ESRD care, its impact on the selection of dialysis modality, on the time of start of dialysis and on the use of an adequate vascular access, are discussed. Finally, the economic aspects of late referral are described and ways to improve the referral pattern are proposed.