Although one-fifth of the United States population is rural, little is known about the characteristics and outcomes of rural dialysis patients. We measured the association of rural residence with patient characteristics, survival, and time to transplant among 552,279 patients who initiated dialysis between January 1, 1995 and December 31, 2002 and survived more than 90 days. We also examined the characteristics of 4363 Medicare-certified dialysis facilities by degree of rurality. Compared with urban patients, rural dialysis patients were older, less racially diverse with a higher prevalence of most co-morbid conditions. Hemodialysis was the dominant modality in both urban and rural areas, although the use of peritoneal dialysis was more frequent in rural areas. Survival and time to transplant differed by racial-ethnic group. Most notably, despite slightly better survival associated with rural vs urban residence among black populations, black populations living in rural areas were less likely to be transplanted than their urban counterparts (and than any other group examined). Compared with urban facilities, rural facilities are smaller, less likely to be for profit or owned by a large chain. Nonetheless, rural facilities perform at least as well as urban facilities based on standard performance measures. Despite more frequent use of peritoneal dialysis among rural patients, rural facilities were markedly less likely to offer peritoneal dialysis or home hemodialysis training than urban facilities. Rural black patients (most of whom live in the south) should be targeted in policies to reduce racial disparities in access to transplant. Further studies are needed to determine whether rural dialysis patients have adequate access to home-based therapies.