Preemptive kidney transplantation is the optimal treatment for pediatric End Stage Renal Disease (ESRD) patients to avoid increased morbidity and mortality associated with dialysis. It is unknown how race/ethnicity and poverty influence preemptive transplant access in pediatric ESRD. We examined the incidence of living donor (LD) or deceased donor (DD) preemptive transplantation among all black, white, and Hispanic children (< 18 years) in the United States Renal Data System from 2000–2009. Adjusted risk ratios for preemptive transplant were calculated using multivariable-adjusted models and examined across health insurance and neighborhood poverty levels. Among 8,053 patients, 1117 (13.9%) received a preemptive transplant (66.9% from LD, 33.1% from DD). In multivariable analyses, there were significant racial/ethnic disparities in access to LD preemptive transplant where blacks were 66% (RR=0.34; 95% CI: 0.28–0.43) and Hispanics 52% (RR=0.48; 95% CI: 0.35–0.67) less likely to receive a LD preemptive transplant vs. whites. Blacks were 22% less likely to receive a DD preemptive transplant vs. whites (RR=0.78, 95% CI: 0.57–1.05) although results were not statistically significant. Future efforts to promote equity in preemptive transplant should address the critical issues of improving access to pre-ESRD nephrology care and overcoming barriers in living donation, including obstacles partially driven by poverty.