The primary objective is to find out the epidemiology, characteristics, preparedness, and survival of elderly patients initiated on dialysis from a tertiary center in Sabah. All newly confirmed patients aged 65 and above who were initiated on renal replacement therapy (RRT) from January 1, 2014, to December 31, 2017, were included. There were two groups of patients: Group 1 – optimally prepared for RRT; Group 2 – suboptimally prepared for RRT. Survival outcome was recorded at the 3rd-, 6th-, and 12th-month interval. Diabetes mellitus accounted for majority of the primary cause of end-stage renal disease, 67.3%. The median duration of follow-up was 550 days (interquartile range = 787). There were 81 patients (30.5%) in Group 1. 182 patients (69.2%) in Group 2 were considered as suboptimally prepared for RRT. The survival of this elderly group was 85.6% at 3 months, 74.5% at six months, and 65% at 1 year. Group 2 patients had much poorer survival outcome compared to Group 1 (56% vs. 85.2% at one year, P <0.001). Age and RRT preparation appeared to be associated with the survival outcome. Decision in initiating dialysis in this group of patients is not as straightforward as in the younger age groups. A more realistic view on the actual survival, as well as consideration regarding the quality of life after the initiation of dialysis, needs to be taken into account. If dialysis therapy is decided, early preparation is important.