Living donor kidney transplant (LDKT) is the best treatment for endstage kidney disease, but there are racial disparities in LDKT rates. To study putative mechanisms of these disparities, we identified 58,752 adult kidney transplant candidates first activated on the United States kidney transplant waitlist 2015–2016 and defined 4 exposure groups by race/primary payer: African American/Medicaid, African American/NonMedicaid, Non-African American/Medicaid, Non-African American/NonMedicaid. We performed competing risk regression to compare risk of LDKT between groups. Among included candidates, 30% had African American race and 9% had Medicaid primary payer. By the end of follow up, 16% underwent LDKT. The cumulative incidence of LDKT was lowest for African American candidates regardless of payer. Compared to African American/Non-Medicaid candidates, the adjusted likelihood of LDKT was higher for Non-African American/Medicaid (HR 1.60, 95%CI 1.43- 1.78) and Non-African American/Non-Medicaid payers (HR 2.66, 95%CI 2.50-2.83). Results were similar when analyzing only candidates still waitlisted >2 years after initial activation or candidates with type O blood. Among 9639 candidates who received LDKT, only 13% were African American. Donor-recipient relationships were similar for African American and Non-African American recipients. These findings indicate African American candidates have a lower incidence of LDKT than candidates of other races, regardless of primary payer.

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