The risk of death is nearly 45% lower in African-Americans than Caucasians undergoing chronic hemodialysis. In light of the higher mortality rate in African-Americans in the general US population, this paradox requires explanation and further investigation. Factors that may contribute to this survival advantage include a younger age at which African-Americans arrive at end-stage renal disease (ESRD) and the slightly higher body mass index. On the other hand, factors, such as lower residual renal function, lower mean hemoglobin and hematocrit, increased prevalence of hypertension, a higher prevalence of catheter use for initial dialysis, and generally lower dose of dialysis should put African-Americans on dialysis at a higher risk of death. This survival advantage seems to be completely annulled with a successful renal transplant. Finally, it should be noted that ESRD carries with it a very high mortality rate in all racial and ethnic groups. A successful renal transplant improves but does not restore the expected remaining life times. Therefore, aggressive approach is required in investigating the factors that confer such high mortality risk on ESRD patients.