2007 CMS/Forum of ESRD Networks’ Annual Meeting

1. Self-Care: Patient & Corporate Perspectives 2007 CMS/Forum of ESRD Networks’ Annual Meeting February 28, 2007

2. Outline • Background on National Renal/Speaker • Right to Select/Making Home Dialysis an Option • Selection Process • Our Commitment/Infrastructure • Training • Clinical Data Points • Benefits of Home Therapy • Challenges of Home Therapy • Patient Testimony • Conclusion

3. Who We Are • National Renal Alliance works to improve the quality and availability of dialysis services for people with kidney disease in medicallyunderserved and select markets. • Along with our physician and hospital partners, we own and operate dialysis centers.

4. Our Mission “National Renal Alliance exists to provide an unequalled level of service to patients with chronic and acute renal disease. We believe this service to be a matter of life, and we commit to exceed the expectations of all that we serve.”

5. About the Speaker Joseph Cashia Founder and Chief Executive Officer -Co-Founder EVP and COO National Nephrology Associates -Co-Founder and COO EVP Development Renal Care Group (NYSE:RCI) -Vice President Operations REN Corporation – USA (OTC:RENL) -Vice President Western Region Community Dialysis Centers (Vivra) -M.B.A. Vanderbilt University’s Owen Graduate School of Management -B.A. History, University of Alabama -B.S. Nursing, Samford University

6. Clinical Oversight Brenda Lepley Chief Operations Officer -Over 30 years of healthcare and management experience -Previous Director of Compliance and Risk Management for National Nephrology Associates -Co-Founder/President/CEO of Integrity Services -Former Vice President of Tennessee Hospital Association -B.S. in Nursing from University of Tennessee

7. Focus on Quality Care "NRA has emerged as a catalyst in changing the landscape of non-urban dialysis services. By bringing services to patients in underserved areas in affiliation with local doctors and hospitals, we are elevating the quality of patient care and the quality of our patient's lives in every market we serve. Ultimately, we intend to set a new standard for quality care in dialysis services.” Joe Cashia, CEO/Founder National Renal Alliance

8. Business Strategy • Acquire or develop dialysis clinics • Acquire or develop hospital-based and independent programs • Develop partnerships with Nephrologists or Hospitals/University’s programs • Offer a unique equity partnership model, which allows partners to purchase minority interests • Foster a complete continuum of care • Promote high quality of care

9. NRA Clinic Footprint 37 operational clinics

10. Self-Care Options • In-Center Self-Care • Peritoneal Dialysis • Home-Hemodialysis It is important to mention that we will be discussing specifically home-hemodialysis and no other methods of self-care.

11. Right to Select CMS requires that all dialysis patients be educated on all of the therapies of treatment available. These therapies include transplant, in-center dialysis, home dialysis and peritoneal dialysis. According to the CMS guidelines, if a facility does not offer any of the therapies, then it is obligated to find a clinic that does offer the therapy option(s). As providers we should ask CMS a pointed question here: Do these patients really have a choice in the first place?

12. Making Home Dialysis an Option National Renal Alliance currently offers home dialysis in fifteen of its facilities. We understand the benefits of home dialysis and the opportunities it can offer to certain patients. For this reason we are committed to offering home dialysis to all patients that we serve. We are currently undergoing the approval process for home-hemodialysis in all of our clinics.

13. Current U.S. Dialysis Modalities 193 1954 10858 14907 60 869

14. Home-Hemodialysis Growth Home-Hemodialysis Patients by Year1 1Source: 2000 – 2004: USRDS 2006 Annual Data Report; 2005 & 2006: USRDS 2004 totals, manufacturers’ public disclosures & NxStage estimates/projections

15. Selection Process • Patients must demonstrate specific cognitive and physical abilities • Adequate and safe water supply • Adequate and safe electrical outlets • A dedicated support person • Sufficient space for machine and supplies

16. Our Commitment • Providing multiple options to patients with kidney failure • Accepting new challenges • Willing to assume uncertain reimbursement environment • Committing to home dialysis in multiple forms including peritoneal dialysis and home-hemodialysis

17. Our Infrastructure • Committed physician support • Committed administrative support • Dedicated FTEs to home dialysis • Training space • Outpatient clinic space and support • Clerical support

18. Training for Home Dialysis • Training resources are within the outpatient clinic • Training takes a minimum of three weeks • Must train patient and the support person • Training requires one nurse per patient

19. Clinical Data Points • Blood Pressure • Phosphorus • Nutrition • Anemia

20. Benefits of Home Therapy • Patients are telling us they feel better than they ever have on dialysis • Patients are excited about the new freedoms home dialysis offers them • Patients have more options to work while on home dialysis then ever before • Patients now have more opportunities to be productive in society • Patients are more independent as a result of home dialysis

21. Challenges • Allocation of Resources • Certification • Reimbursement

22. What OurPatients are Saying….

23. In Conclusion • Self-care using home-hemodialysis modality shows positive results • Early outcomes are showing daily therapy can extend and improve the lives of dialysis patients • The biggest challenge regarding home dialysis is training • Reforms regarding reimbursement for home dialysis need to be implemented • Our belief is that home-hemodialysis is one of the truest form of self-care