Each year approximately 110,000 new patients start chronic dialysis treatment in the U.S. This public health metric is known as the end-stage renal disease (ESRD) incidence rate. 

Over the past 10 years the annual ESRD incidence rate per million U.S. population has remained stagnant or even shown sporadic downward trends. 

More interestingly, and probably for the first time in this country, the absolute number of new dialysis patients per year has declined despite ongoing population growth. Does this mean that the growth of the dialysis industry in the U.S. will come to a grinding halt?

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Additional factors may contribute to re-shaping the future of the dialysis industry, including changes in practice pattern and finances. There has been a recent trend to initiate dialysis treatment later in the course of chronic kidney disease (CKD) progression. This new approach is inspired by a number of recent studies that suggest no favorable effect or even harmful outcomes upon earlier dialysis initiation. 

Some data suggest that in very old CKD patients a more conservative approach without dialysis treatment may be the better approach. These new views, no matter how controversial they are, have already started impacting our practice pattern. 

There are additional challenges with chronic dialysis therapy in the U.S., especially if the government’s imminent plans to cut the dialysis treatment reimbursement by 9.4% are implemented in 2014. 

Since dialysis patient attrition is quite high given the regretfully high mortality of 20% annually in the U.S., along with high kidney transplantation rates and patient withdrawals, the decline in the ESRD incidence rate will likely mean that for the first time in our history we may see increasing numbers of vacant hemodialysis (HD) seats during our dialysis rounds. 

This may be a new phenomenon for American nephrologists, but Canadian and British colleagues are quite familiar with it, and this has led to trimming some HD shifts and ultimate closure of many dialysis clinics without a replacement. In the U.S., the struggle may further be intensified by recent trend to transition more patients from HD to the better incentivized peritoneal dialysis and the recent emergence of new dialysis clinics at every corner of the block in town by the competing dialysis chains. 

The latter observation suggests that rival dialysis companies have not yet felt the need for better coordination of plans and efforts as a unified front. Even more vulnerable may be the independent dialysis centers, although it is hard to predict which sector will be affected most. The only effective way to counter these unavoidable trends is to improve dialysis patient survival and to lower hospitalization.