patients might be expanded for people whose age, co-morbidities and lack of family support are relative contraindications to peritoneal dialysis by providing trained staff to assist either automated or continuous ambulatory peritoneal dialysis at home as is done in some other countries. In the United States, healthcare worker assisted peritoneal dialysis is not covered by Medicare and utilizing it would likely eliminate some of the cost savings of home peritoneal dialysis versus in-center hemodialysis (Brown and Wilkie 2016). The next step is patient choice. Not all people eligible for peritoneal dialysis will choose it when they are educated and given a choice of dialysis modalities to undertake. Studies suggest that about half of patients offered an informed dialysis modality choice will choose peritoneal dialysis (Blake et al. 2013; Brown and Wilkie 2016; Little et al. 2001). Interestingly, most medical professionals (physicians and nurses) treating renal disease say they would strongly prefer home peritoneal dialysis or home hemodialysis over center based hemodialysis for themselves (Schiller et al. 2010). Following patient selection and consent to peritoneal dialysis, a catheter must be placed in the abdominal cavity. Surgeons or interventional radiologists who can place the catheters need to be available, a factor that often limits access to peritoneal dialysis when dialysis must be started urgently. Not every attempt placing a catheter is successful. Sometimes the placement cannot be completed or the catheter is placed but will not function adequately to allow peritoneal dialysis. Even after successful catheter placement, some patients or their family members are unable or unwilling to learn how to carry out peritoneal dialysis in a safe manner. About 15 percent of patients with attempted catheter placements will not succeed in performing home peritoneal dialysis (Blake et al. 2013). Taking into account the attrition at each step of the process suggests that between 17 to 34 percent of ESRD patients could be receiving peritoneal dialysis. If we subtract out the ESRD patients who have received a transplant and apply this range to the population of ESRD patients currently on dialysis (509,014) there should be 86,532 to 173,065 patients who could be on peritoneal dialysis.10 Since about 10 These figures likely represent an upper bound since the 17-34 percent applies to all ESRD patients. Patients eligible for peritoneal dialysis are generally healthier than patients who end up on hemodialysis. But many of the CEA • Increasing the Number of Kidney Transplants to Treat End Stage Renal Disease 11 7 percent of ESRD disease patients (51,057 patients or about 10 percent of dialysis patients) are currently on peritoneal dialysis (USRDS 2018), an additional 35,475 to 122,008 patients could be moved from hemodialysis to peritoneal dialysis. These estimates of the numbers of patients who could be receiving peritoneal dialysis are in line with a recently reported study of an effort to move dialysis patients in an integrated healthcare delivery onto peritoneal dialysis (Pravoverov et al. 2019). Over an 11-year period utilization of peritoneal dialysis among new dialysis patients increased from 15.2 to 33.8 percent however, only 80 percent of these patients continued peritoneal dialysis one year after initiation (Pravoverov et al. 2019). Potential Cost Savings from Peritoneal Dialysis: It is unlikely that large numbers of current hemodialysis patients would move to peritoneal dialysis because most of these patients are now comfortably receiving hemodialysis. Relative to new ESRD patients, many current hemodialysis patients would likely be unable or unwilling to move to a new treatment modality. A better estimate of the number of patients willing to switch would probably start by looking at the 124,675 new (incident) cases of ESRD each year. Currently, 9.7 percent of incident ESRD cases are initially treated with peritoneal dialysis. Moving this peritoneal dialysis percentage to 17-34 percent would add an additional 9,101 to 30,296 peritoneal dialysis patients each year. This would yield roughly $135 to $450 million in annual savings. However, these cost savings may narrow once beneficiary health and location are considered. Thus, the benefit from moving additional ESRD patients from hemodialysis to peritoneal dialysis may lead to smaller gains then estimated. Regardless of the potential cost savings, the needs of the ESRD patient ultimately dictate the type of treatment they should receive. Comparative Moving to Kidney Transplantation The Organ Procurement and Distribution System The Organ Procurement and Transplantation Network (OPTN) is a non-profit entity that was established by Federal statute to run the nationwide organ procurement and distribution system (42 United States Code § 274). The United Network for Organ Sharing (UNOS) is a private, non-profit organization that has run the OPTN under contract with the Federal Government since 1986. CMS has designated 58 Organ Procurement Organizations (OPOs) nationwide that manage the organ procurement, recovery, and allocation process within exclusive geographic areas designated as Donation Service Areas (DSA). Each OPO must join and abide by the rules of the OPTN (42 CFR §486.320). There is only one OPO per DSA