*Purpose: Compared to White Canadians, African, Caribbean and Black (ACB) Canadians with end stage kidney disease (ESKD) are less likely to receive a 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”). In a cross-sectional convenience sample of adults with ESKD in Toronto, ethnicity 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 analyzed in multivariable logistic regression.

*Results: Among the 590 participants (mean[SD] age 57[13] years, 62% male), 24% were ACB, and 42% were White. ACB participants were less likely to have >12 years of education (44% vs 64%, p<0.001) and incomes of >$30K/year (39% vs 71%, p<0.001) compared to White participants. The summed LDKT scores and DDKT pro scores were similar between the groups. However, ACB participants rated perceived DDKT con scores (12[5,16] vs 9[5,13]; p=0.002) higher than Whites. In univariable analysis, ACB participants were more likely to indicate that perceived "trouble paying for medications" (OR, 2.28 [95% CI: 1.44, 3.59), "taking many medications post-transplant" (OR, 2.47 [95% CI: 1.69, 4.42]), "pain from surgery" (OR, 1.83 [95% CI: 1.11, 3.11]) and potential "health problems due to transplant" (OR, 1.83 [95% CI: 1.11, 3.02) were important to their decision about transplant compared to Whites. After adjusting for sociodemographic variables, comorbidity and transplant knowledge at baseline, the importance of "taking many medications post-transplant" (OR, 2.11 [95% CI: 1.27, 3.51) and "trouble paying for medications" (OR, 1.72 [95% CI: 1.02, 2.90) remained associated with ACB ethnicity in the final logistic regression model. However these associations were not significant after adjusting for transplant knowledge for "pain from surgery" (OR, 1.56 [95% CI: 0.89, 2.72]) and "health problems due to transplant" (OR, 1.45 [95% CI: 0.89, 2.36).

*Conclusions: Concerns about the quantity of post-transplant medications and anticipated financial strain are associated with KT decisions among ACB Canadians with ESKD compared to Whites. Further qualitative research is needed to better understand the reasons for these ethnicity-specific differences in decision making.

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