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Renal replacement therapy (RRT)--encompassing hemodialysis, peritoneal dialysis, and kidney transplantation--provides life-sustaining treatment for the expanding end-stage renal disease (ESRD) population. There is an excess burden of ESRD in African-American, Hispanic, Native Americans, and Asian/Pacific Islanders. Moreover, there is mounting evidence to suggest that significant racial and ethnic disparities exist in RRT--including referral and initiation of dialysis, adequacy of dialysis, and anemia management--with non-white patients usually at a disadvantage. In addition, there are cultural and sociodemographic differences that lead to racial variation in the choice of ESRD modality. Lastly, in certain ethnic ESRD populations, there are a series of complex issues, from biologic to socioeconomic, which limit kidney transplantation--the treatment of choice. Despite these inequalities, which are often associated with negative outcomes, these non-white groups have better hemodialysis survival rates than white patients. It is essential to develop strategies to address the disparities in ESRD treatment among minority groups in order to minimize the differences in RRT provision and identify the factors that confer improved dialysis survival-thus improving care for all Americans with kidney disease.