Predialysis nephrologist care is associated with morbidity and mortality in incident dialysis patients, but the relationship with access to kidney transplantation (KT) is unclear. From a national study of incident US dialysis patients, we identified 2253 patients with detailed information about predialysis care, sociodemographic characteristics and comorbidities. We used multivariate Cox proportional hazards models to study associations between predialysis nephrology care and two outcomes: time from first dialysis to the first day on the KT wait-list, and time to first KT. Two-thirds of patients first encountered a nephrologist >3 months prior to dialysis and one-third <or=3 months prior to dialysis (early vs. late nephrologist care; ENC vs. LNC). Overall, 515 patients were added to the KT wait-list and 406 underwent KT during follow-up (2.3 years). In multivariate analyses, ENC was associated with a 41% (95%CI: 15-72%) greater rate of being wait-listed compared to LNC and a 54% (95%CI: 22-96%) greater rate of KT. Similar associations existed with number of predialysis nephrology visits. Earlier and more frequent predialysis nephrologist care were associated with greater access to the KT wait-list as well as a higher rate of KT, indicating that LNC may augment existing inequalities that impair access to KT.