*Purpose: The purpose of this study was to assess racial/ethnic and sex differences in access to the renal transplant deceased donor waiting list among incident dialysis patients, accounting for pre-waitlisting mortality as a competing risk.

*Methods: After excluding prior renal transplant recipients (n=1,291) and pre-emptive transplants (n=522), we identified a retrospective cohort of all incident adult dialysis patients from January 1, 2015 – December 31, 2016 and followed this cohort through December 31, 2018 via the United States (US) Renal Data System. We used adjusted Fine Gray sub-distribution hazards regression with median imputation to assess racial/ethnic and sex differences in waitlisting accounting for pre-waitlist mortality as a competing risk and adjusting for demographic, clinical and socioeconomic factors.

*Results: Among 129,910 US incident dialysis patients, 16.2% (n=20,993) were waitlisted and 26.8% (n=34,814) died before waitlisting. White men (n=42,150, 32.4%) and white women (n=28,293, 21.8%) represented the largest demographic groups among incident dialysis patients, followed by Black men (n=18,200, 14.0%) and Black women (n=15,612, 12.0%). The proportion of waitlisting within each group was highest among Asian men (33.1%) and white men (30.0%), while Black women (17.0%) and white women (14.6%) had the lowest waitlisting proportion. The proportion of pre-waitlisting deaths within each group was highest among white women (58.0%), white men (58.0%), and black women (51.7%), and lowest among Asian males (38.9%). In adjusted analyses accounting for pre-waitlist mortality, Black women (hazard ratio (HR): 0.73, 95% confidence interval (CI): 0.70, 0.77), Black men (HR: 0.82, 95% CI: 0.78, 0.86), white women (HR: 0.86, 95% CI: 0.82, 0.89), and Hispanic women (HR: 0.91, 95% CI: 0.86, 0.96) experienced reduced likelihood of waitlisting compared to white men. (Figure 1).

*Conclusions: Racial/ethnic and sex disparities in access to waitlisting for renal transplantation remain after accounting for pre-waitlisting mortality, particularly among female and Black dialysis patients. Notably, Black women appear to experience a compounded disadvantage in access to waitlisting compared to their white female and Black male counterparts. Future work should intervene on improving early access to transplant education, referral, and medical evaluation for these demographic groups.

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