*Purpose: Compared to White Canadians, Asian Canadians with end stage kidney disease (ESKD) are less likely to receive living donor kidney transplant (LDKT). We explored factors associated with kidney transplant (KT) decision-making, specifically the weight patients give to perceived pros and cons for KT decisions.

*Methods: Using the Transplant Decisional Balance survey, patients rated the importance of perceived pros and cons to KT decision-making from 1-5 (“not important”-“extremely important”). We surveyed a cross-sectional convenience sample of adults with ESKD in Toronto. Ethnicity (White, Asian [South and East], other) was self-identified. Individual ratings of pro/con items were summed to yield LDKT and deceased donor KT (DDKT) pro/con scores. Individual scale items were also examined: dichotomized (not/slightly/moderately vs very/extremely important) and their independent association with ethnicity was analyzed in multivariable logistic regression.

*Results: Among 590 participants (mean[SD] age 57[13] years, 62% male), 24% were Asian, and 42% were White. Asians were less likely to have incomes >$30K/year (52% vs 71%, p<0.001) and were more likely to be immigrants (75% vs 27%, p<0.001) compared to Whites. The summed LDKT scores and DDKT pro scores were similar between the groups. However, Asian participants rated perceived DDKT con scores (median [IQR]: 12[7,16] vs 9[5,13]; p=0.025) higher than Whites. In univariable analysis, compared to White participants, Asian participants were more likely to indicate that perceived “pain from surgery” (OR, 2.20 [95% CI: 1.30, 3.37]), “taking many medications post-transplant” (OR, 2.18 [95% CI: 1.40, 3.38]), and "if transplant failed it would be a lot of work/pain for nothing" (OR, 3.02 [95% CI: 1.75, 5.21) were very/extremely important to their transplant decision. These associations remained significant after adjusting for sociodemographic variables, comorbidity, and transplant knowledge at onset, (OR, 2.16 [95% CI: 1.23, 3.78]), (OR, 2.22 [95% CI: 1.37, 3.60]), (OR, 3.30 [95% CI: 1.83, 5.95], respectively).

*Conclusions: Anticipated pain, concerns about the quantity of post-transplant medications and potential unsuccessful transplant weighs into KT decision making among Asian Canadians with ESKD more than for White Canadians. Further qualitative research is needed to better understand the reasons for these ethnicity-specific differences in decision making.

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