*Purpose: Racial/ethnic minority patients face reduced access to kidney transplantation. We hypothesized that this disparity may be magnified if patients also have major psychosocial liabilities such as ongoing substance abuse. We examined the prevalence of tobacco, alcohol, and illicit drug use in patients seeking evaluation for transplant, as well as whether minorities who used substances were less likely to be listed for transplant than white patients.

*Methods: 1152 patients being evaluated for kidney transplant at an eastern US center were prospectively enrolled between 3/2010-10/2012. Demographic data were obtained from patient interview. Medical records of patients’ psychosocial/medical evaluations for transplant were reviewed for substance use history and monitored through 8/2014 (ie, minimum of ~2 y post-evaluation) to identify those listed for transplant. Associations of substance use with race/ethnicity were examined; survival analysis tested whether these factors predicted time to listing, controlling for other clinical and demographic factors.

*Results: The cohort was 68% white, 23% African American (AA), and 8% other races/ethnicities (Native American, Hispanic, or Asian). AAs were more likely than white patients or patients of other ethnicities to smoke cigarettes currently (24%/14%/16%, respectively, p=.001). The 3 groups did not differ in rate of current heavy drinking, as defined by National Institute on Alcohol Abuse & Alcoholism criteria (3%/2%/1%, p=.486), but they differed on current illicit drug use (8%/3%/9%, p<.001). The cumulative incidence of listing for transplant was 90% for white patients who did not use substances. Other groups differed from this referent group (p≤.003). Thus, not only white substance users but all AAs (even non-users) were less likely to be listed than the referent group. If other racial/ethnic minority patients did not use substances, they were as likely as the referent group to be listed. However, if they used substances they were least likely of all groups to be listed.

*Conclusions: Both substance use and race/ethnicity affect likelihood of listing. The combination of these factors may lead to unique disadvantage for minority patients, but AAs face disparities in listing even without substance use. Transplant professionals should be alert to such effects and seek ways to eliminate them.

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