BACKGROUND: Renal transplantation is the therapy of choice for patients with end-stage renal disease (ESRD). However, African Americans' (AA) access to this modality is not commensurate with that of other races. This imbalance, coupled with AA disproportionately representing those with ESRD, has kept AA disadvantaged compared with other races, especially whites. METHODS: We reviewed published reports that examined the connection between race and the incidence of chronic renal failure, access to optimal therapy, and outcomes of renal transplantation. RESULTS: The incidence of ESRD in AA is 4 times greater than in whites, but AA remain less likely than whites to be referred for or undergo renal transplantation. Also, AA are at greater risk than whites to experience premature graft failure. CONCLUSIONS: ESRD management has improved dramatically with the advent of successful renal transplantation. However, AA remain significantly disadvantaged in both access and outcomes compared with whites. Further evaluation of underlying causes and development of specific remedies is warranted.