BACKGROUND AND OBJECTIVES: Half the individuals who reach ESRD are working age (< 65 years old) and many are at risk for job loss. Factors that contribute to job retention among working-age patients with chronic kidney disease before ESRD are unknown. The purpose of the study is to understand factors associated with maintaining employment among working-age patients with advanced kidney failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective study we reviewed the United States Renal Data System database (1992 through 2003) and selected all patients (n = 102,104) who were working age and employed 6 months before dialysis initiation. Factors that were examined for an association with maintaining employment status included demographics, comorbid conditions, ESRD cause, insurance, predialysis erythropoietin use, and dialysis modality. RESULTS: Maintaining employment at the same level during the final 6 months before dialysis was more likely among (1) white men ages 30 to 49 years; (2) patients with either glomerulonephritis, cystic, or urologic causes of renal failure; (3) patients choosing peritoneal dialysis for their first treatment; (4) those with employer group or other health plans; and (5) erythropoietin usage before ESRD. Maintaining employment status was less likely among patients with congestive heart failure, cardiovascular disease, cancer, and other chronic illnesses. CONCLUSIONS: The rate of unemployment in working-age patients with chronic kidney disease and ESRD is high compared with that of the general population. Treating anemia with erythropoietin before kidney failure and educating patients about work-friendly home dialysis options might improve job retention.