of the abdominal cavity – the peritoneum - as a filter. Sterile fluid containing Dextrose and other additives – the dialysate - is infused into the abdominal (peritoneal) cavity through a permanent, surgically placed catheter, left for several hours during which waste products and extra fluid are removed through filtration through the peritoneum, and then the fluid is drained off. Usually four or more exchanges per day are needed and they are typically performed manually by the patient or a caregiver, often a family member. This is sometimes called continuous ambulatory peritoneal dialysis. One type of peritoneal dialysis, automated peritoneal dialysis, uses a machine to do several of these fluid exchanges overnight while the patient is asleep. Transplantation is the best form of renal replacement therapy. While a transplant recipient requires ongoing monitoring and medications, kidney transplantation both reduces medical spending on ESRD treatment and is associated with better long-term outcomes for the recipient. In 2018, for example, the life expectancy for ESRD patients who receive transplant is more than double the life expectancy on dialysis across all age groups (USRDS 2018). Healthy kidneys for transplantation can be obtained from deceased donors or from a living donor. All donor organs must be matched for blood type and immunological compatibility7 with the recipient or the recipient’s immune system will reject the organ. Living donation is possible because humans have two kidneys and it is possible to live a healthy life after donating a kidney with the remaining kidney. Transplants from living donors generally have a higher success rate and higher long-term graft survival than kidneys from deceased donors, because the elective nature of living donation allows for better immunological matching between donors and recipients and the opportunity to maximize the health of the recipient and the donor organ (OPTN 2019e). 8 Most living donors direct their donation to specific recipients. In 2018, 3,474 living donors were family members and another 1,678 living donors were directed to an unrelated recipient. Unfortunately, not every potential recipient has a compatible family member or friend to ask as a donor. A small number of living donors altruistically donate to strangers (338 in 2018). Kidney transplantation is a major surgery with known complications for both living donors and recipients. Living donors must weigh future risks associated with kidney donation—including an increased likelihood of high blood pressure and potential increases in long-term kidney failure rates (Weill Cornell Medicine n.d.)—against their willingness to donate a kidney to those in need. All kidney transplant recipients must take immunosuppressive drugs, which have harmful side effects, to keep their immune systems from rejecting the foreign organ they have received. After transplantation, recipients must adopt a renal friendly health diets and lifestyles that are critical to maintaining the transplant. In addition, transplantation is not a permanent cure since transplanted kidneys do not 7 This entails matching the donor and recipient’s ABO blood types (A, B, AB, and O) and typing and cross-matching antigenic markers known as human leukocyte antigens (HLA). 8 We procured all OPTN data in this paper from the OPTN website on October 24, 2019. CEA • Increasing the Number of Kidney Transplants to Treat End Stage Renal Disease 5 always function for the lifetime of the recipient, with 21.4 percent of primary transplanted kidneys failing within 5 years. Despite these shortcomings, transplantation is the best treatment for ESRD. Among new (incident) cases of ESRD in 2016, 87.3 percent were initially treated with hemodialysis, 9.7 percent with peritoneal dialysis, and 2.8 percent received a preemptive kidney transplant (USRDS 2018). Peritoneal dialysis and transplant were markedly more common among the small number of younger ESRD patients with 28.6 percent of new 0-21 year old ESRD patients on peritoneal dialysis and 19.9 percent receiving transplant. These percentages quickly declined with increasing patient age (USRDS 2018). At the end of 2016, among the 726,331 prevalent ESRD cases, 63.1 percent were receiving renal replacement therapy through hemodialysis, 7 percent with peritoneal dialysis, and 29.6 percent had a functioning kidney transplant (USRDS 2018). Compared to other countries, the United States has a lower percentage of ESRD patients treated by kidney transplantation and peritoneal dialysis as well as a higher percentage treated by hemodialysis (USRDS 2018; Scholten et al. 2019). CEA • Increasing the Number of Kidney Transplants to Treat End Stage Renal Disease 6 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Thailand Romania Serbia Macedonia Chile Albania Colombia Turkey United States Brazil Jordan Saudi Arabia Uruguay Slovakia Poland Italy Hong Kong Belarus Belgium, French sp. Canada Iraq Jalisco (Mexico) Qatar France Australia Iran Switzerland Austria Spain Latvia United Kingdom* Estonia Netherlands Iceland Norway Transplant In-Center HD Home HD CAPD/APD/IPD Figure 1. Distribution of Type of Renal Replacement Therapy Modality Used by ESRD Patients, by Selected Country, 2016 Percent Source: United States Renal Data System. Note: United Kingdom data includes England, Wales, and Northern Ireland. CEA •