And, indeed, up to 50 of patients without medical contraindications for PD or HD selected PD [34,51?4]. Patients with no previous PD information could not choose PD. Thus, we may expect higher rates of PD in the near future after increasing the number of specialized predialysis care staff at our clinics and streamlining the choice process [12,21,34,50?1]. In this regard, we are planning to assess the impact of implementing the routine use of “decision-making aids” from 2014 [55]. Most authors have described better outcomes, longer survival, higher proportion of planned dialysis start and more PD choice for patients switched into specialized predialysis programs than if followed-up by a general nephrologist [23,50,56]. In this regard, we did not observe significant differences in terms of PD take on, probably related with the low number of clinics staffed by a specialized predialysis nephrologist and nurse during 2012. The shortage of nephrologists that some of these countries face does not permit a universal predialysis care specialization.ConclusionsAlthough patients were frequently followed-up from the time of CKD diagnosis, referral patterns to ICS clinics have not been fully successful in Eastern Europe. Unplanned start was frequent and may explain the low frequency of PD. Despite the high rate of late referral,PLOS ONE | DOI:10.1371/journal.pone.0155987 May 26,10 /Referral, Modality and Dialysis Start in an International Settinginformation and education were widely provided but probably not consistently structured and not long enough in duration due to the late referral. Measures such as implementation of referral patterns, reinforcement of predialysis staff specialization and routine use of decision-making aids may facilitate optimal care, improving well-being and planning of RRT start as well as increased PD use.AcknowledgmentsAlberto Ortiz for critically reading and commenting on the draft version of the manuscript. Helen de la Maza edited the manuscript for English usage. The following authors were part of the consortium d.PD Clinics Eastern Europe and were led by Bel Marr : [email protected] Bel Marr 1, Diaverum Home Therapies. Medical Office, Munich, Germany. Janusz Ostrowski2, Jaroslaw Kcki2, Pawel Kochman2, Roman Papis2 and Tomasz Jankowski2, Wloclawek Diaverum Clinic, Wloclawek, Poland. Marietta T 3, Szeged Diaverum Clinic, Szeged, Hungary. Delia Timofte4, Lacramiora Medrihan4, Andina Mandit? and Monica Nitu4, Semaparc Diaverum Clinic, Bucharest, Romania. Attila Orosz5 and Erzsebet N eth5, Bajcsy Diaverum Clinic, Budapest, Hungary. Andrzej Kosicki6, Przemysl Diaverum Clinic, Przemysl, Poland. Alicja Calka7 and Marcin Sarna7, Olsztyn Diaverum Clinic, Olsztyn, Poland. Bayer 41-4109 biological activity Daniela Moro8 and Ioan Boca8, Sibiu Distributei Diaverum Clinic, Sibiu, Romania. Dezider K a9, Zalaegerszeg Diaverum Clinic, Zalaegerszeg, Hungary. Jen?Redl10 and M. Mester-Szabo10, Szolnok Diaverum Clinic, Szolnok, Hungary. Catalin Tacu13, Industriilor Diaverum Clinic, Bucharest, Romania. Waldemar lizie14 and Klaudiusz Wojnarowski14, Gdynia Diaverum Clinic, Gdynia, Poland. Marcin Drobisz15 and Piotr Strzelczyk15, Katowice Diaverum Clinic, Katowice, Poland. Krzysztof Doskocz16, Nysa Diaverum Clinic, Nysa, Poland. Anna Bednarek-Skublevska17, Lublin Diaverum Clinic, Lublin, MLN9708 biological activity Poland and Department of Nephrology, the Medical University in Lublin, Poland Raluca Mocanu18, Roman Diaverum Clinic, Roman, Romania. Magyar Katalin19, Baja Diaverum Clinic, Baja,.And, indeed, up to 50 of patients without medical contraindications for PD or HD selected PD [34,51?4]. Patients with no previous PD information could not choose PD. Thus, we may expect higher rates of PD in the near future after increasing the number of specialized predialysis care staff at our clinics and streamlining the choice process [12,21,34,50?1]. In this regard, we are planning to assess the impact of implementing the routine use of “decision-making aids” from 2014 [55]. Most authors have described better outcomes, longer survival, higher proportion of planned dialysis start and more PD choice for patients switched into specialized predialysis programs than if followed-up by a general nephrologist [23,50,56]. In this regard, we did not observe significant differences in terms of PD take on, probably related with the low number of clinics staffed by a specialized predialysis nephrologist and nurse during 2012. The shortage of nephrologists that some of these countries face does not permit a universal predialysis care specialization.ConclusionsAlthough patients were frequently followed-up from the time of CKD diagnosis, referral patterns to ICS clinics have not been fully successful in Eastern Europe. Unplanned start was frequent and may explain the low frequency of PD. Despite the high rate of late referral,PLOS ONE | DOI:10.1371/journal.pone.0155987 May 26,10 /Referral, Modality and Dialysis Start in an International Settinginformation and education were widely provided but probably not consistently structured and not long enough in duration due to the late referral. Measures such as implementation of referral patterns, reinforcement of predialysis staff specialization and routine use of decision-making aids may facilitate optimal care, improving well-being and planning of RRT start as well as increased PD use.AcknowledgmentsAlberto Ortiz for critically reading and commenting on the draft version of the manuscript. Helen de la Maza edited the manuscript for English usage. The following authors were part of the consortium d.PD Clinics Eastern Europe and were led by Bel Marr : [email protected] Bel Marr 1, Diaverum Home Therapies. Medical Office, Munich, Germany. Janusz Ostrowski2, Jaroslaw Kcki2, Pawel Kochman2, Roman Papis2 and Tomasz Jankowski2, Wloclawek Diaverum Clinic, Wloclawek, Poland. Marietta T 3, Szeged Diaverum Clinic, Szeged, Hungary. Delia Timofte4, Lacramiora Medrihan4, Andina Mandit? and Monica Nitu4, Semaparc Diaverum Clinic, Bucharest, Romania. Attila Orosz5 and Erzsebet N eth5, Bajcsy Diaverum Clinic, Budapest, Hungary. Andrzej Kosicki6, Przemysl Diaverum Clinic, Przemysl, Poland. Alicja Calka7 and Marcin Sarna7, Olsztyn Diaverum Clinic, Olsztyn, Poland. Daniela Moro8 and Ioan Boca8, Sibiu Distributei Diaverum Clinic, Sibiu, Romania. Dezider K a9, Zalaegerszeg Diaverum Clinic, Zalaegerszeg, Hungary. Jen?Redl10 and M. Mester-Szabo10, Szolnok Diaverum Clinic, Szolnok, Hungary. Catalin Tacu13, Industriilor Diaverum Clinic, Bucharest, Romania. Waldemar lizie14 and Klaudiusz Wojnarowski14, Gdynia Diaverum Clinic, Gdynia, Poland. Marcin Drobisz15 and Piotr Strzelczyk15, Katowice Diaverum Clinic, Katowice, Poland. Krzysztof Doskocz16, Nysa Diaverum Clinic, Nysa, Poland. Anna Bednarek-Skublevska17, Lublin Diaverum Clinic, Lublin, Poland and Department of Nephrology, the Medical University in Lublin, Poland Raluca Mocanu18, Roman Diaverum Clinic, Roman, Romania. Magyar Katalin19, Baja Diaverum Clinic, Baja,.