Rates of treated end-stage renal disease have risen relentlessly throughout the Western world over the past 30 years, with little indication of a slowing in the rate. This increase has a number of causes, such as important trends in disease prevalence, changing population structure, and changing treatment patterns. A number of biases also affect measured rates of renal replacement therapy. These biases include lead-time and length bias, as well as classification bias. A further important effect will be changes in competing risks, in particular, changing mortality from cardiovascular disease. We examine the effects of these factors by analyzing data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Rates of treated ESRD have risen steadily over the past 30 years, which appears to be the result of several factors. Rates among older people have increased particularly, as have rates among Australian and New Zealand indigenous peoples. Higher rates are also seen among some immigrant groups. Accentuating the effect of these changing rates are changes in the structure of the population and the tendency to commence treatment earlier. The increase in rates of ESRD treatment is often ascribed to an explosion of kidney disease. Although a major contribution comes from increasing disease prevalence, understanding the implications of this increase requires comprehension of a number of other factors.