There is presently much debate about the optimal flow chart of pre-end-stage renal disease (ESRD) and ESRD patients. This article summarizes two important nonmedical factors that affect the outcome of ESRD patients in Europe: late referral and the structure of the health care system. In a European survey, 30% of patients were referred to a nephrologist less than 1 mo before the start of renal replacement therapy (RRT). This had an impact on the modality choice, as 77.5% of late versus 51.1% of early referrals were started on hemodialysis. Hospitalization at start of RRT was longer in late versus early referrals (15.1 +/- 16.0 versus 27.8 +/- 23.7 d respectively, P < 0.001). There were more patients without antihypertensive medication in the late referral group (28.6% versus 15.5%, P = 0.004), and diastolic BP in this group was higher (83.5 +/- 15.8 versus 74.4 +/- 15.0 mmHg, P = 0.03). One year after the start of dialysis, the number of deaths in the late referrals was higher (26.7 versus 16.4%, P = 0.07) and the number of transplanted patients was lower (4.7 versus 17.5%, P = 0.02). Creatinine clearance at start of RRT was 7.0 +/- 3.5 ml/min in the patients who died during the first year after start of RRT versus 9.5 +/- 3.6 ml/min in those surviving. Only 18% of patients were started with a creatinine clearance > 10 ml/min, as recommended by the Dialysis Outcomes Quality Initiative guidelines. It is concluded that late referral to a nephrologist is still a major problem that has a negative influence on modality choice for peritoneal dialysis, and on morbidity and mortality of ESRD patients.