Peritoneal dialysis (PD), despite being advantageous to patient, physician, and society, has failed to show the growth it deserves. On the contrary, PD utilization has declined. Over the past several years, we have noticed a decline in the number of our home dialysis patients. When compared to the national trend, we find our trend to be not significantly different from other centers across the country. A similar trend has also been noticed in Canada. Although several reasons may exist for the decline, we intend to concentrate on local factors. In the first quarter of 1996, we had a total of 46 adult and pediatric end-stage renal disease (ESRD) patients on PD. That number decreased to 23 at the end of fourth quarter of the year 2001. The losses in our program far exceeded the gains. We lost our patients mainly to in-center hemodialysis (ICHD) and to transplantation. Peritonitis and membrane failure remained the major grounds for the loss to ICHD. In our center, geographic location and a lack of structured pre-ESRD education probably played a major role in the decline. Many of our patients are from distant counties that have a contract with University of Texas Medical Branch for providing health care to their indigent population. However, once those patients develop complications, the counties rely on the expertise of local physicians and nephrologists.