Year, by Modality, 2004–16 Expenditures (thousands of dollars) Source: United States Renal Data System. CEA • Increasing the Number of Kidney Transplants to Treat End Stage Renal Disease 9 Long-term survival is better for kidney transplant recipients than ESRD patients on dialysis, but in part this may reflect the fact that healthier patients are selected for placement on transplant lists (Wolfe et al. 1999). Nevertheless, when kidney recipients are compared with similar patients who are on the wait list but still on dialysis, there is still a survival advantage. While the risk of death is significantly higher in the post-operative period, reflecting the risk of surgery and the initiation of immunosuppressive therapy, it rapidly declines and the long-term survival of transplant recipients starts to exceed that of dialysis patients in a year or less post- transplant (Wolfe et al. 1999; Tonelli et al. 2011; Kaballo et al. 2018). The patient survival benefit of transplantation versus dialysis persists even when less than ideal (marginal) kidneys are used, although the benefits are smaller than when ideal kidneys are used (Ojo et al. 2001). ESRD patients on dialysis have decreased participation in the workforce. Peritoneal dialysis appears to be associated with increased likelihood of being employed compared to hemodialysis but the effect is uncertain and likely small. A recent Swedish study found that peritoneal dialysis was associated with a four-percentage point higher probability of employment over hemodialysis and a six-percentage point lower probability of being on disability (Ghani et al. 2019). Yet, while cross-sectional studies have found that peritoneal dialysis patients are more likely to be employed than hemodialysis patients, it is difficult to determine the direction of causation. Given that it is more likely that healthier individuals with ESRD choose peritoneal dialysis, it may not be the treatment modality but rather the health of the patient that accounts for the differences in employment between peritoneal dialysis and hemodialysis. Other studies utilizing different analyses suggest that treatment modality does not influence the ability to be employed but that there may be a small effect of employed patients preferentially choosing peritoneal dialysis (Just et al. 2008). Hence, a study that found that peritoneal dialysis patients who worked in the year before starting dialysis were 2.5 times more likely to continue employment in the four months after starting dialysis than hemodialysis patients. This study concluded that “it is likely that patient characteristics, rather than dialysis modality, function as the main determinants of employment status, but using a therapy such as peritoneal dialysis can make employment more feasible, and patients may select or be recommended for peritoneal dialysis to facilitate their employment” (Kutner et al. 2010, 2044). Similarly, Van Manen et al. (2001, 600) found that employment fell from 31% to 25% for hemodialysis patients and from 48% to 40% for peritoneal dialysis patients after one year of starting dialysis and concluded that the, “findings suggest treatment modality does not influence ability to maintain employment, but that employment may influence the choice of hemodialysis or peritoneal dialysis.” Most studies report higher participation rates in life activities (physical function, travel, recreation, work) for kidney transplant patients than either peritoneal dialysis or hemodialysis (there was no difference between the two types of dialysis) (Purnell et al. 2013). A recent Swedish study reported that the probability of being employed one year after treatment was 21 percentage points higher for transplant recipients than dialysis patients. This effect increased to 38 percentage points after five years due to worsening outcomes and conditions on dialysis (Jarl et al. 2018). In summary, kidney transplantation is superior to dialysis in terms of lower cost, longer life expectancy, better quality of life, and higher productivity. Other than lower annual cost, there is little difference CEA • Increasing the Number of Kidney Transplants to Treat End Stage Renal Disease 10 between the two types of dialysis. A 2013 review of the worldwide literature concluded that peritoneal dialysis and hemodialysis are “clinically equivalent modalities” with similar 1,2,3,4 and 5 year survivals and quality of life “…we will thus consider hemodialysis and peritoneal dialysis as perfect substitutes from an economic standpoint” (Karopadi et al. 2013, 2533). Moving from Hemodialysis to Peritoneal Dialysis There are multiple steps to place a patient on peritoneal dialysis with attrition at each step that limit the total number of ESRD patients who can undergo peritoneal dialysis. The first is patient selection. Not every ESRD patient can receive peritoneal dialysis. Contraindications include previous abdominal surgeries, large abdominal wall hernias, morbid obesity, intra-abdominal inflammatory and infectious conditions like diverticulitis, large abdominal aortic aneurysm, and a place of residence that does not permit peritoneal dialysis. Relative contraindications or barriers to peritoneal dialysis include physical barriers like impaired vision and dexterity and cognitive barriers like dementia, psychiatric illness and a history of non-adherence. Estimates of patients eligible to do peritoneal dialysis range between 40 and 80 percent (Blake et al. 2013). The number of eligible