SIGNIFICANCE The incidence and prevalence of end-stage kidney disease (ESKD) cases in the US nearly doubled in the 1990s. In the US population, more than 590,000 adults are currently treated for ESKD, and another 7.4 million have chronic kidney disease, which typically advances to ESKD. The aging of baby boomers, changing racial distributions, and increasing prevalence of diabetes in the US indicates that the prevalence of ESKD will continue to rise. In 2010, the US spent more than $27 billion in Medicare funds to treat patients with ESKD. Medicare costs per person per year range from $32,914 for KT patients, to $66,751 on peritoneal dialysis, to $87,561 for hemodialysis. This amount does not include the money paid by private health insurers as well as other sources of public health coverage such as the VA and state funds or Medicaid. Although about 90% of that cost goes toward dialysis treatment as the most popular modality for ESKD treatment, kidney transplantation (KT) is the optimal treatment for end-stage kidney disease (ESKD). It reduces mortality, improves quality of life, and is less costly than dialysis. Patients who can get a KT before starting dialysis, fare better post-transplant than those who are transplanted after they have started dialysis. Further, living donor KT (LDKT) is better than deceased donor KT (DDKT) because: (a) patients who can identify a living donor (LD) will get a KT much more quickly than ones awaiting DDKT7, and, (b) LDKT yields better outcomes than DDKT by improving cost effectiveness, reducing morbidity, and increasing long-term survival.