Little is known about chronic dialysis patients' reasons for electing renal transplantation. We investigated chronic dialysis patients' reasons for choosing to be listed or not listed for renal transplantation. Chronic dialysis patients were asked to complete a questionnaire consisting of demographic information and questions related to desire for transplantation and previous transplant experience. The mean age of the dialysis population was 48 +/- 15 years (range 16 to 81 years); the population was 61% women, 39% African American, and 26% diabetic. The questionnaires of the 95 patients eligible for transplantation were analyzed. Forty-four percent of the eligible patients were active on a transplant waiting list; 56% of patients refused transplantation. Twenty-nine percent of the surveyed patients had had at least one previous transplant. Listed patients were younger (43 vs. 52 years), had fewer years of ESRD (5 vs. 9 years), and were more likely to be on home dialysis therapy (55% vs. 32%). There were no differences between listed and unlisted patients in gender, race, years of education, marital status, children, diabetes mellitus, and previous transplant experience. African American patients reporting strong religious beliefs were less likely to be listed for transplantation (76% vs. 24%); religious beliefs were not related to white patients' listing for transplantation. The most reported reason for electing transplantation was "hoping for a better quality of life" (86% of respondents). More never-transplanted patients elected transplantation "hoping it will make me live longer" (69% vs. 25% with previous transplant) and because their doctor (50% vs. 6%) or family (42% vs. 6%) thought it was a good idea. Of patients who declined transplant, 92% with previous transplant experience indicated that the experience discouraged them from seeking retransplantation; 59% of patients without transplant experience reported that seeing what happened to others with a failed transplant affected their decision not to seek transplantation. Our findings suggest that race and gender differences in electing transplant may disappear when all patients are actively solicited for transplantation. However, older patients may be less likely to elect transplant because they are more satisfied with life on dialysis or less willing to take risks. Further study of patients' reasons for electing transplantation is required before demographic variations in transplant choices can be accurately interpreted.