Financial circumstances force some stable renal transplant recipients to discontinue cyclosporine (CsA). Previous results from our center document a subgroup of these patients at increased risk for acute rejection and allograft loss, namely, those of African ancestry. After 1988, such disadvantaged recipients have been able to receive CsA at no charge through the National Organization for Rare Disorders (NORD). At the University of Alabama at Birmingham, 54 patients were enrolled in the NORD program between 1988 and 1994. Acute rejection, allograft survival, and patient survival in these patients were compared with those in 42 patients who, prior to 1988, were withdrawn from CsA for financial reasons. Both groups were similar socioeconomically. The mean follow-up was 69 ± 33 months (±SD) in the withdrawal group and 45 ± 14 months in those entering the NORD program. Acute rejections occurred with similar frequency in both groups before CsA withdrawal (45%) or NORD enrollment (48%). In contrast, acute rejections were more common in patients after the onset of CsA withdrawal (38%) than after NORD enrollment (11%) (P < 0.01). Black patients withdrawn from CsA experienced more acute rejections than their counterparts in the NORD program (57% v 15%) (P < 0.01). White NORD recipients also experienced fewer acute rejections, although the difference was not statistically significant (withdrawal group 16% v NORD group 4%; P = 0.29). Rejection episodes were accompanied by reduced graft survival in black patients withdrawn from CsA, while significant improvement was seen in those remaining on CsA-based therapy (P < 0.05). No difference in allograft survival was seen among white patients in either group (withdrawal group 74% v NORD group 82%; P = 0.33). Thus, long-term access to CsA through the NORD program reduced acute rejections and improved allograff survival in an economically disadvantaged subgroup of renal transplant recipients. These findings emphasize the importance of continued access to CsA in black renal transplant recipients and its influence on long-term allograft survival.