Data from the Michigan Kidney Registry and the US Renal Data System (USRDS) show that the number of patients receiving treatment for end-stage renal disease (ESRD) increased sevenfold following the introduction of Medicare coverage for ESRD in 1973. The number of new patients added per year has also increased dramatically--approximately fourfold. Initial selection criteria for acceptance into the ESRD Program included age less than 65 years and absence of systemic diseases such as diabetes. During the past 18 years, the gradual acceptance of older patients and of diabetic patients has led to an increase in the median age of new patients from 46 to 61 years and a 12-fold increase in the incidence of treatment in patients with ESRD due to diabetes. Given the broad acceptance of sicker and older patients, withdrawal from dialysis has become a consideration when dialysis no longer benefits the patient. Treatment modalities have also changed, and increasing numbers of patients undergo successful renal transplantation or receive continuous ambulatory peritoneal dialysis (CAPD). During the 1980s, hemodialysis treatment times and dialysis staffs decreased; however, several improvements in the care of patients on dialysis occurred during this period.