High solid anaerobic digestion (HSAD) achieves the benefits of high volumetric loading rates and lower reject water production, which, however, results in much more concentrated reject water with a remarkable increase in organics and nitrogen compared with that from conventional AD with low solid content. The high concentrations of ammonium (2000–3500 mg/L) and COD (3000–4000 mg/L) were reported to exert inhibition on anammox bacteria (AnAOB), posing challenges to the application of the partial nitritation/anammox (PN/A). To date, no cases of PN/A process start-up for sludge HSAD reject water were reported. This study demonstrated the start-up process of a 480 m3/d PN/A project without anammox sludge inoculation and treating HSAD reject water from a centralized dewatered sludge treatment plant. The project did not construct new infrastructures but utilized previously constructed tanks to upgrade the process from existing short-cut nitrification-denitrification to a two-stage PN/A process. Although no external anammox sludge inoculation was performed to save seeding sludge cost, the start-up was successfully achieved in about 9 months (273 days) based on a three-step method of “AnAOB enrichment - sludge acclimation - capacity doubling”. During start-up, the relative abundance of AnAOB (Candidatus_Kuenenia) increased from near zero to 12.0%. After start-up, the total inorganic nitrogen (TIN) removal load reached 0.74 kgN/(m3•d), with a total nitrogen removal efficiency of over 90%. Compared to the traditional nitrification-denitrification process, the PN/A process remarkably reduces the addition of organic chemicals and aeration energy consumption, saving approximately 4.2 million yuan (RMB) in operational costs annually. In summary, this research provides a full-scale reference for the start-up of the PN/A process treating sludge HSAD reject water.