Each year, approximately 120,000 Americans transition to maintenance dialysis therapy while 90,000 dialysis patients die and 20,000 undergo kidney transplantation. The result is a small positive balance of 10,000 added dialysis patients each year on top of the nation’s prevalent dialysis population of 450,000. The trivial differential, a narrow margin of growth of 2% to 3%, is the basis on which the dialysis industry capitalizes its growth and expansion in the United States. 

Now imagine that, in the not-too-distant future, fewer people transition to dialysis and mortality and transplantation rates remain the same. The margin of growth will be even narrower. The positive balance will shrink and may even go into the negative zone. This likely scenario leads to unfilled dialysis chairs and increasing vacancies in hemodialysis shifts. Dialysis centers struggling for survival will try hard to go directly to the source of new dialysis patients, the so-called “ESRD fountains,” such as large community hospitals. An ESRD fountain can be defined as a medical center complex where each month 4 or more people are started on chronic dialysis treatment in that center. These new dialysis patients are then discharged to 1 of the 6,000 dialysis clinics in the country.

An ESRD fountain that sends out 4 or more new dialysis patients each month contributes to at least 45-50 new patients a year. This is the number needed to keep a 150-patient dialysis clinic operational, given that each year a center will lose about one third of its patients due to death, transplantation, geographic relocations, and other factors. There are also “near-fountains,” such as medical centers with 2–3 new ESRD patients a month.

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A dialysis center needs to be linked to at least 1 ESRD center or several near-fountains to survive, let alone grow or expand beyond its usual modalities to offer, for example, home dialysis. Nephrology groups often compete for access to ESRD fountains.  The competition can be tough to the point that some nephrology groups provide free CKD clinics in some of the mega-fountains (more than 6 new ESRD patients a month). Dialysis companies try hard to contract with nephrology groups that have more secure access to ESRD fountains.

The geographic location of a dialysis clinic also plays a role. A dialysis clinic in the middle of a neighborhood with more minorities, including African Americans and Hispanics, have a better chance of surviving or even growing than a dialysis unit in an upscale area even if the population is elderly.

As the rate of acceleration in ESRD incidence continues to drop, we should expect heightened battles for the ESRD fountains.

Kam Kalantar-Zadeh, MD, MPH, PhD is the Medical Director, Nephrology, and Professor and Chief of the Division of Nephrology & Hypertension at the University of California, Irvine School of Medicine.