1| INTRODUCTION
Chinese chronic kidney disease (CKD) population is constantly on the rise along with increasing number of diabetes and hypertensive patients1,2. China Kidney Disease Network (CK-NET) 2015 Annual Data Report showed that the percentage of hospitalized patients with CKD accounted for 4.8% among chronic patients3. If not well detected and managed, CKD may progress to end-stage renal disease (ESRD), at which stage patients have to rely on renal replacement therapy (RRT) to maintain physical functioning. It’s predicted that worldwide amount of RRT usage will more than doubled by 20304 and each year hundreds of thousands of ESRD patients is newly registered in European and American5. Advanced CKD patients with whose eGFR <30 mL/min/1.73m2 and declining are in transitional period and dialysis modality decision has been ranked as their top 10 priorities6,7. Not only that, numerous decision points are extended in succession surrounding treatment decisions such as dialysis initiation. In China, the alternative RRT options include in-center hemodialysis (HD), peritoneal dialysis (PD), kidney transplantation as well as conservative kidney management, an acceptable option for older ESRD patients. No matter which treatment decision will affect or even decide patients’ lifestyle and the quality of life. Consequence of the ultimate decision determines the necessity of patients involving treatment decision-making progress to implement shared decision making (SDM)8. However, previous researches have demonstrated barriers from different perspectives, including predialysis education, communication and cultural factors9-11. More recently, one study analyzed residential location played a significant role in treatment decision-making12, which may be applicable to status quo of China. In fact, the healthcare system in China is a three-level system, consisting of primary, secondary and tertiary care according to different regions. Besides, the prevalence of CKD in Chinese rural population is relatively high and similar to urban population2,13, deepen the association between CKD health service system and uran-rural areas. Global clinical practice guidelines recommend early or timely referral to a predialysis care at least 12 months before patients starting RRT14. However, there is evidence that ESRD patients receive dialysis passively without full physical and mental preparation15,16. Studies reported over 50% ESRD patients undergo urgent dialysis or unplanned dialysis, associated with patients’ poor prognosis and huge societal healthcare burdens17. As the limit of Chinese nephrology medical resource and patients’ resistance to nephrology preparation, unplanned and crush dialysis are common for ESRD patients18,19. On the other hand, self-referral is much more prevalent in the Chinese context of decentralized CKD management 20. Although Chinese multi-tiered medical system encourage referral rather than self-referral20, the urgent challenge for self-referral patients with advanced CKD and health care professionals is to conduct RRT decision meetings and make treatment decisions. Understanding how Chinese patients with advanced CKD to achieve self-referral and clarify the relationship between self-referral and treatment decision-making are crucial to nephrology clinical practice and promote policy reform. Previous researched have focused on referral or treatment decision-making independently. Therefore, the aim of this qualitative study was to explore experience and perspectives of advanced CKD patients and healthcare professionals regarding self-referral and treatment decision-making.