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The two major therapies for end-stage renal disease are dialysis and kidney transplantation. During hemodialysis an extracorporeal circuit with a dialysis mem-brane is used to filter and clean the blood; peritoneal dialysis uses the body’s own peritoneal cavity to transfer solutes and toxins between the blood and the peritoneal dialysis fluid.

The incident hemodialysis population is now nearly eight times larger than in 1978, and in 2006 topped 100,000 pa-tients for the first time. The number of new peritoneal dialysis patients peaked at 9,407 in 1995, and has since fallen to 6,725; this population now accounts for 6.2 percent of new dialysis patients, a ratio that continues to decline from its 1982–1985 peak of 15 percent.

As of December 31, 2006, nearly 328,000 patients were receiving hemodialysis therapy, 26,082 were on peritoneal dialysis (8.2 percent of the dialysis population), and 151,502 had a functioning graft. The annual rate of growth has slowed in the prevalent hemodialysis population, from 8.5 percent in 1996 to 3.9 percent in 2006, while the peritoneal dialysis population has remained quite stable. The greatest growth has occurred in the transplant population, which has increased 5.5–6.0 percent each year since 2001.

The number of patients who receive a kidney transplant as their first ESRD therapy reached 2,635 in 2006, and since 1996 has grown an average of 7.3 percent each year. In the prevalent population, the number waiting to receive a trans-plant reached nearly 69,000 in 2006, with an annual growth of 10.1 percent since 1996, though this rate of change has fallen to 7–8 percent in the last three years. Chapter Seven presents additional information on the wait-listed dialysis population, including the numbers of active and inactive patients on the list.

In the incident hemodialysis population, Medicare only, Medicare plus Medicaid, and Medicare under HMOs or man-aged care plans continue to cover 75 percent of patients, while employer group health plans (EGHPs) and Medicare as secondary payor cover the remaining 25 percent. Among new

peritoneal dialysis patients, in contrast, the 2006 distribution was 63 and 37 percent. Medicare covers only 35 percent of incident transplant patients; 34 percent have Medicare as secondary payor coverage, and 31 percent are covered by other insurers. These differences may significantly affect both patient benefits — particularly those related to prescription drugs — and provider revenue streams from services such dialysis therapy, injectables, treatments and medications for transplantation, and diagnostic testing.

Differences in payor distribution continue in the preva-lent population, but are less dramatic than those seen with incident patients. Eighty-four percent of hemodialysis pa-tients have Medicare as their primary payor, compared to 79 and 54 percent of those on peritoneal dialysis and with a transplant..

Maps of incident rates by modality illustrate nationwide changes since 1995–1996, changes which may reflect the recent consolidation of ESRD providers, their varying policies regarding therapy, and their individual likelihoods of using dialytic and transplant therapies in the incident population. The rates may also reflect changes in access to organs for transplantation. Changes in peritoneal dialysis use, for ex-ample, show distinct geographic patterns that differ from the distribution of the hemodialysis population. Although there has been a general decline in use of this therapy, shown also in maps of the prevalent population, there continue to be notable exceptions, including the Dakotas, Nebraska, Oklahoma, Louisiana, Mississippi, and Alabama, where use has increased.

The growing consolidation of providers into larger chains has long been clear, and two large chains now treat the great majority of dialysis patients in the U.S. In the early 1990s, just one in seven dialysis patients received treatment in a chain-owned unit; in 2006, the number was nearly seven in ten. The market share of independent units has been relatively stable, at 18–19 percent since 2000; hospital-based units, however, are now treating just 11 percent of the prevalent

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Hemodialysis (2006: 327,754)Peritoneal dialysis (26,082)Transplant (151,502)OPTN transplant wait-list (68,576)

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Hemodialysis (2006: 101,306)Peritoneal dialysis (6,725)Total dialysis (108,219)Transplant (2,635)

contentsincident modality · 8�2 counts & rates • patient distribu-

tion by first modality & unit type • patient distribu-tion by payor • geographic variations in incident rates

prevalent modality · 8�4 counts & rates • patient distribution by modality & unit type • patient distribution by payor

• geographic variations in prevalent rates home hemodi-alysis · 8�6 patient demographics • patient distribution by state & by geographic location

highlightstable 4.a In 2006, the rate of ESRD incidence reached 330 per million popula-tion for hemodialysis, 21.9 for peritoneal dialysis, and 8.0 for transplant. figure 4.3 Chain-owned dialysis providers continue to increase their market share, treating 64 percent of incident hemodialysis patients in 2006, up from 55 percent in 2000. figure 4.4 Medicare as secondary payor coverage varies by modality, at 10.0, 20.4, and 33.8 percent for hemodialysis, peritoneal dialysis, and transplant, respectively. table 4.b The overall rate of ESRD prevalence in 2006 reached 1,053 per million population for hemodialysis, 84 for perito-neal dialysis, and 487 for transplant. The rate for African Americans reached 3,979 — nearly six times greater than the rate of 685 among whites, and twice as high as the rate among Native Americans.

dialysis population. With the use of peritoneal dialysis vary-ing considerably by provider group, further consolidation may raise concerns over modality choice and its relation to provider practices.

With peritoneal dialysis long the dominant home therapy, home hemodialysis has received little attention in the past 15 years. Its use peaked in 1985, with 5,817 prevalent patients. A number of government programs, paying home aids to help deliver the therapy, ended soon afterwards, contribut-ing to a steady decline in use until by 2002 there were only 1,756 patients. Now, however, there appears to be renewed interest in the use of daily home therapy. The prevalent population reached 2,455 in 2006, with 838 new individuals starting the therapy in 2005–2006. This renewed interest has been fueled by publication of results for single centers using daily home hemodialysis, and new products are being introduced for the delivery of this therapy. In addition, a new NIH study is in progress, comparing daily or overnight home hemodialysis to in-center therapy, and testing safety and efficacy. Currently, the largest concentration of home hemodialysis patients is found in Illinois and Florida, with patients in an urban setting accounting for 75 percent of the prevalent population under treatment.

During the past decade, then, modality use has changed considerably. Hemodialysis is still dominant, while use of peritoneal dialysis is concentrated in fewer areas of the country. Differences in the accumulation of patients on different modalities need to be carefully considered, not only from the vantage point of quality of care, but in terms of payor distribution and incentives, which may influence modality choice and the availability of services. Use of home hemodialysis appears to be resurging, based on new applications of daily home therapies such as short treat-ments of 2–3 hours as well as overnight therapy 5–6 days per week. These trends will require increased evaluation in the future.

II4.2 Prevalent patient counts (USRDS), by modality December 31 point prevalent ESRD patients

figure 4.1 incident ESRD patients; peritoneal dialysis counts include CAPD & CCPD only. figure 4.2 December 31 point prevalent patients; peritoneal dialysis counts include CAPD & CCPD only. OPTN was created in 1986.

II4.1 Incident patient counts (USRDS), by first modality incident ESRD patients

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II4.3 Incident patient counts, by first modality & unit type incident dialysis patients

figure 4.3 Chain-owned dialysis providers continue to increase their market share, treating 64 percent of incident hemodialy-sis patients in 2006, up from 55 percent in 2000. This change is concurrent with a fall in the number of new hemodialysis patients treated in hospital-based units, from 21 to 15 percent. The percentage of incident perito-neal dialysis patients treated in chain-owned units, in contrast, has remained stable for several years, and with the recent sale of the providers most likely to employ this modal-ity (Gambro has been purchased by DaVita, and RCG by Fresenius), future use of this therapy is in question.

II4.a Incident counts & rates per million population, 2006, by age, gender, race, ethnicity, & primary diagnosis incident ESRD patients; unknowns dropped

Number of patients Rate per million populationHD PD Tx Unk. HD PD Tx Unk.

Age

0-19 643 393 183 12 7.3 4.7 2.2 0.220-44 11,698 1,200 696 33 108.8 11.2 6.5 0.345-64 36,738 2,763 1,216 70 566.8 40.9 16.7 1.065-74 23,445 1,297 296 40 1,362.7 71.6 15.5 2.175+ 27,011 947 28 21 1,687.2 54.6 1.5 1.1

Gen. Male 55,548 3,595 1,438 101 415.0 25.7 9.8 0.7

Female 43,987 3,005 981 75 263.7 18.8 6.4 0.5

Race

White 65,024 4,791 1,919 139 251.5 18.9 7.7 0.6African American 29,496 1,401 203 19 962.2 41.6 5.8 0.6Native American 1,074 70 37 * 449.0 26.5 12.3 *Asian 3,941 338 260 15 342.0 26.7 18.3 1.1

Eth. Hispanic 12,456 720 183 12 492.2 22.8 5.0 0.4

Non-Hispanic 87,079 5,880 2,236 164 316.4 21.7 8.4 0.6

Prim

ary d

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osis Diabetes 44,901 2,699 521 36 148.4 8.9 1.7 0.1

Hypertension 27,700 1,462 239 19 91.8 4.9 0.8 0.1Glomerulonephritis 6,463 885 480 18 21.4 3.0 1.6 0.1Cystic kidney 1,804 403 394 21 6.0 1.3 1.3 0.1Other urologic 1,477 93 58 * 4.9 0.3 0.2 *Other cause 12,280 803 481 41 40.8 2.7 1.6 0.1Unknown/missing 4,910 255 246 36 8.1 0.4 0.4 0.1All 99,535 6,600 2,419 176 329.5 21.9 8.0 0.6

table 4.a In 2006, nearly 100,000 new ESRD patients began therapy on hemodialysis, 6,600 were placed on peritoneal dialysis, and 2,419 received a preemptive transplant (these numbers exclude patients with missing demographic information). The rate of ESRD incidence reached 330 per million population for hemodialysis, 21.9 for peritoneal dialysis, and 8.0 for transplant. Considerable differ-ences by race persist in these rates, with the rate for African Americans beginning ther-apy on hemodialysis, for example, reaching 962 per million population, compared to 252 among whites. The incident rate for those receiving a preemptive transplant, in contrast, is greatest in the Asian population, at 18.3 per million population, compared to 12.3, 7.7, and 5.8 among Native Americans, whites, and African Americans, respectively.

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206 243 278 321 386 455

13.7 17.4 21.3 25.8 32.6 42.9

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II4.4 Incident patient distribution, by first modality & payor incident ESRD patients

II4.5 Geographic variations in unadjusted incident rates (per million population), by first modality & HSA incident ESRD patients

figure 4.4 Nearly one in two new hemodialysis patients is covered solely by Medicare, 14.4 percent are dually-enrolled (Medicare/Med-icaid), and 11.5 percent are covered by a Medi-care HMO provider — up from 8.7 percent in 2005. Medicare covers 45.4 and 27.8 percent, respectively, of peritoneal dialysis and trans-plant patients, while 10.4 and 4.7 percent are dually-enrolled and 7.2 and 2.8 percent have HMO coverage. Medicare as secondary payor coverage also varies by modality, at 10.0, 20.4, and 33.8 percent for hemodialysis, peritoneal dialysis, and transplant, respectively.

figure 4.5 The choice of initial modality continues to vary across the country. The incident rate for patients beginning ESRD therapy on hemodialysis, for example, is greatest on the East Coast and in the southeastern states, while the rate for patients with a preemptive transplant is highest in the Upper Midwest. In the 2005–2006 hemodialysis population, the mean rate in the upper quintile is 2.5 times greater than in the lower; regions with the highest transplant rates have a mean rate 3.8 times greater than those with the lowest.

table 4.a incident ESRD patients; unknowns dropped. Rates by age adjusted for gender & race, rates by gender adjusted for age & race, rates by race & ethnicity adjusted for age & gender, & rates by primary diagnosis adjusted for age, gender, & race. *Values for cells with ten or fewer patients are suppressed. figure 4.3 incident dialysis patients; peritoneal dialysis includes CAPD & CCPD only. figure 4.4 incident ESRD patients; peritoneal dialysis includes CAPD & CCPD only. figure 4.5 incident ESRD patients, by HSA, unadjusted. Excludes patients residing in Puerto Rico & the Territories. For details on how to read the map legends, please see page xvi in the Introduction.

Hemodialysis: 19�9�5–19�9�6

Peritoneal dialysis: 19�9�5–19�9�6

Transplant: 19�9�5–19�9�6

Hemodialysis: 2005–2006

Peritoneal dialysis: 2005–2006

Transplant: 2005–2006

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II4.6 Prevalent patient counts, by modality & unit type December 31 point prevalent dialysis patients

figure 4.6 Between 2000 and 2006, the per-centage of prevalent patients treated by chain-owned providers rose from 58.1 to 66.4 per-cent for hemodialysis, and from 54.8 to 64.9 for peritoneal dialysis. Hospital-based units, in contrast, now treat just 11.4 and 13.2 per-cent of prevalent hemodialysis and peritoneal dialysis patients, down from 18.1 and 21.5 per-cent in 2000. This year the USRDS acquired new cross-reference data that allow us to iden-tify units that were previously missing their hospital-based designation, and to update our patient counts for these units. Numbers in this figure, and in Figure 4.3, thus differ from those presented in previous ADRs.

II4.b Prevalent counts & rates per million population, 2006, by age, gender, race, ethnicity, & primary diagnosis December 31 point prevalent ESRD patients

Number of patients Rate per million populationHD PD Tx Unk. HD PD Tx Unk.

Age

0-19 1,201 815 5,001 57 13.4 9.6 59.4 0.620-44 44,656 5,633 43,043 269 415.7 52.7 403.8 2.545-64 130,134 11,229 75,877 391 2,012.8 163.2 1,054.8 5.665-74 72,921 4,667 19,515 89 4,361.2 259.5 1,074.8 4.975+ 71,050 3,094 3,953 29 4,569.5 179.2 212.8 1.7

Gen. Male 174,899 13,311 87,353 488 1,288.5 94.6 597.1 3.4

Female 145,063 12,127 60,036 347 867.2 75.9 385.4 2.2

Race

White 176,940 16,787 110,267 542 684.6 66.1 440.6 2.2African American 124,184 6,743 28,213 236 3,978.9 195.9 822.4 6.6Native American 4,809 330 1,537 11 2,000.1 124.7 562.6 3.9Asian 14,029 1,578 7,372 46 1,184.0 119.6 524.5 3.3

Eth. Hispanic 44,578 2,903 16,917 119 1,717.8 93.5 511.6 3.4

Non-Hispanic 275,384 22,535 130,472 716 1,001.6 83.3 488.5 2.7

Prim

ary d

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osis Diabetes 140,630 8,568 34,323 185 462.1 28.2 113.1 0.6

Hypertension 91,440 6,173 22,563 127 300.9 20.4 74.2 0.4Glomerulonephritis 33,241 4,615 40,067 204 109.7 15.3 132.4 0.7Cystic kidney 7,969 1,340 13,947 56 26.2 4.4 45.8 0.2Other urologic 6,896 634 5,508 29 22.8 2.1 18.3 0.1Other cause 27,622 3,062 21,301 159 91.3 10.2 70.7 0.5Unknown/missing 12,164 1,046 9,680 75 20.1 1.7 16.0 0.1All 319,962 25,438 147,389 835 1,053.1 83.9 486.6 2.8

table 4.b At the end of 2006, nearly 320,000 ESRD patients were receiving hemodialysis therapy, 25,438 were being treated with peri-toneal dialysis, and 147,389 had a functioning graft (these numbers exclude patients with missing demographic information). Patients age 45–64 constitute the largest portion of the prevalent population by age, from 41 per-cent of those on hemodialysis to 52 percent of those with a transplant. The overall rate of ESRD prevalence in 2006 reached 1,053 per million population for hemodialysis, 84 for peritoneal dialysis, and 487 for transplant. The rate for African Americans, however, reached 3,979 — nearly six times greater than the rate of 685 among whites, and twice as high as the rate among Native Americans.

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II4.7 Prev. pt distribution, by modality & payor Dec. 31 point prevalent ESRD pts

II4.8 Geographic variations in unadjusted prevalent rates (per million population), by modality & HSA December 31 point prevalent ESRD patients

figure 4.7� Nine in ten prevalent hemodialysis patients had some type of Medicare cover-age in 2006; 43 percent were covered only by Medicare, while one-third were dually-enrolled in both Medicare and Medicaid — a number varying little since the mid-1990s. Medicare also covers nine of ten peritoneal dialysis patients, though 50 percent are cov-ered solely by Medicare, and just 24 percent are dually-enrolled. In the transplant popu-lation, in contrast, just 34 percent are cov-ered by Medicare alone. Transplant patients younger than 65 and not disabled lose their entitlement three years after the transplant.

figure 4.8� Rates by modality in the prevalent ESRD population show the same general patterns as those for incident patients. The rate for hemodialysis patients is greatest in the south and southeastern portions of the country, while for patients with a functioning graft the rates are greatest in the northern states. In the 2006 hemodialysis population, the mean rate in the upper quintile was 3.3 times higher than in the lower; regions with the highest transplant rates have a mean rate just 1.7 times greater than those with the lowest.

table 4.b December 31 point prevalent ESRD patients; unknowns dropped. Rates by age adjusted for gender & race, rates by gender adjusted for age & race, rates by race & ethnicity adjusted for age & gender, & rates by primary diagnosis adjusted for age, gender, & race. figure 4.6 December 31 point prevalent dialysis patients; peritoneal dialysis includes CAPD & CCPD only. figure 4.7� December 31 point prevalent ESRD patients; peritoneal dialysis includes CAPD & CCPD only. figure 4.8� December 31 point prevalent ESRD patients, by HSA, unadjusted. Excludes patients residing in Puerto Rico & the Territories. For details on how to read the map legends, please see page xvi in the Introduction.

Hemodialysis: 19�9�6

Peritoneal dialysis: 19�9�6

Transplant: 19�9�6

Hemodialysis: 2006

Peritoneal dialysis: 2006

Transplant: 2006

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Age

0-19 . .20-44 95 11.345-64 271 32.365-74 165 19.775+ 307 36.6

Gen. Male 472 56.3

Female 366 43.7

Race

White 551 65.8African American 257 30.7Native American * 0.1Asian 20 2.4Other/unknown * 1.1

Eth. Hispanic 81 9.7

Non-Hispanic 757 90.3

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Diabetes 302 36.0Hypertension 290 34.6Glomerulonephritis 43 5.1Cystic kidney 15 1.8Other urologic 13 1.6Other cause 86 10.3Unknown/missing 89 10.6All 838 100.0

II4.11 Incident home HD patients, by geographic location incident home HD pts

II4.9 Percentage of inc. home HD pts in the top 10 states inc. home HD pts, 05–06

II4.10 Incident dialysis patients, by modality & assistance incident dialysis patients, 2006

table 4.c Of the 838 patients beginning ESRD therapy on home hemodialysis in 2005–2006, nearly one-third were age 45–64, and 37 per-cent were age 75 and older. Fifty-six percent of these new patients were male, two in three were white, and one in ten was Hispanic. Pri-mary diagnoses of diabetes and hyperten-sion each accounted for 35–36 percent of the population.

figure 4.10 New ESRD patients treated with home hemodialysis therapy are far more likely to be receiving assistance (see caption for definition) than those treated with center hemodialysis or with peritoneal dialysis. In 2006, 57 percent of incident home hemodi-alysis patients were on assistance, compared to 16 and 5 percent, respectively, of those on center hemodialysis and peritoneal dialysis. These data may seem to imply that home hemodialysis patients are astonishingly disabled. Many of those classified as home patients, however, may be institutionalized and receive their dialysis in the nursing home setting.

figure 4.11 In 2006, the percentage of incident home hemodialysis patients living in urban locations reached 87 percent, up from 62 per-cent in 1992. The percentage living in rural locales, in contrast, fell from 35 percent in 1992 to just 9.9 percent in 2006.

figure 4.9� Illinois and Florida accounted for 56 percent of the incident home hemodialysis population in 2005–2006, with 29.4 and 26.3 percent, respectively. Eight percent of patients receiving home hemodialysis therapy resided in Ohio, and 3–4 percent in Texas, Georgia, California, New York, and Michigan.

II4.c Home hemodialysis: incident patient distribution inc. home HD pts, 2005–2006

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ColumnTotal percent

Age

0-19 21 0.920-44 494 20.145-64 1,084 44.265-74 462 18.875+ 394 16.0

Gen. Male 1,479 60.2

Female 976 39.8

Race

White 1,614 65.7African American 754 30.7Native American 12 0.5Asian 65 2.6Other/unknown * 0.4

Eth. Hispanic 156 6.4

Non-Hispanic 2,299 93.6

Prim

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Diabetes 737 30.0Hypertension 661 26.9Glomerulonephritis 457 18.6Cystic kidney 133 5.4Other urologic 84 3.4Other cause 290 11.8Unknown/missing 93 3.8All 2,455 100.0

home hemodialysis

II4.14 Prevalent home HD patients, by geographic location prev. home HD pts

II4.12 Percentage of prv. home HD pts in the top 10 states prv. home HD patients, 2006

II4.13 Prevalent dialysis patients, by modality & assistance prev. dialysis patients, 2006

figure 4.13 Differences by modality in the per-centage of patients receiving assistance are less striking in the prevalent population than among incident patients. In 2006, 10 percent of prevalent home hemodialysis patients were on assistance, compared to 6 percent of those on center hemodialysis and 2 percent of those treated with peritoneal dialysis.

figure 4.14 The percentage of prevalent home hemodialysis patients residing in urban loca-tions has been rising slowly since the late 1980s, and reached 74 percent in 2006. This growth has been paralleled by a decline in the rural location, which is now at 24 percent.

table 4.d Of the nearly 2,500 prevalent patients treated with home hemodialysis in 2006, 44 percent were age 45–64, and six in ten were male. Sixty-six percent were white, and just 6.4 percent were Hispanic. And primary diag-noses of diabetes and hypertension accounted for 30 and 27 percent, respectively, of the prev-alent home hemodialysis population.

figure 4.12 Seventeen percent of prevalent home hemodialysis patient in 2006 lived in Illinois, while Florida, Texas, and Califor-nia accounted for 8.5, 7.8, and 6.5 percent, respectively.

II4.d Home hemodialysis: prevalent patient distribution prev home HD patients, 2006

table 4.c & figure 4.9� incident home hemodialy-sis patients, 2005–2006 combined. *Values for cells with ten or fewer patients are suppressed.

“.” Zero values in this cell. figure 4.10 incident dialysis patients, 2006. Peritoneal dialysis con-sists of CAPD & CCPD only. figure 4.11 incident home hemodialysis patients. table 4.d & figure 4.12 December 31 point prevalent home hemodialy-sis patients, 2006. figure 4.13 December 31 point prevalent dialysis patients, 2006. Peritoneal dialy-sis consists of CAPD & CCPD only. figure 4.14 December 31 point prevalent home hemodialysis patients. • In figures 4.10 & 4.13, assistance is defined as a patient who has any one of the fol-lowing pre-existing conditions, as identified on the Medical Evidence form: inability to ambulate, inability to transfer, needs assistance with daily activities, institutionalized, assisted living, nursing home, or other institution.

108328 26 69152

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88

chapter summary

Patients beginning ESRD therapy on dialysis in 2006 (4.1)

Prevalent patients on hemodialysis, 2006 (4.2)

Prevalent patients on peritoneal dialysis, 2006 (4.2)

Patients wait-listed for a kidney transplant, 2006 (4.2)

Prevalent patients with a transplant, 2006 (4.2)

Patients beginning ESRD therapy with a transplant in 2006 (4.1)

Incident hemodialysis patients treated in chain-owned units (4.3)

Prevalent hemodialysis patients treated in chain-owned units (4.6)

Incident patients dually-enrolled in Medicare/Medicaid, 2006 (%, 4.4)

Prevalent patients dually-enrolled in Medicare/Medicaid, 2006 (%, 4.7)

HD

HD

Tx

Tx

PD

PD

Rate of new ESRD pts starting therapy on hemodialysis in 2006 (per million pop.; 4.a)

Prevalent ESRD patients on hemodialysis in 2006 (per million population; 4.b)

Rate of new ESRD pts starting therapy on peritoneal dialysis in 2006 (per million pop.; 4.a)

Prevalent ESRD patients on peritoneal dialysis in 2006 (per million population; 4.b)

Rate of new ESRD pts starting therapy with a transplant in 2006 (per million pop.; 4.a)

Prevalent ESRD patients with a functioning transplant in 2006 (per million pop.; 4.b)

Prevalent U.S. home HD pts treated in Illinois, Florida, Texas, or California (4.13)