Although the incidence of end-stage kidney disease is 34% higher in US Hispanics than non-Hispanics, the latter have a lower mortality rate following initiation of dialysis (107 vs 206 per 1,000 patient-years).1,2 Outcomes have not been examined in Puerto Rico, a US territory where 4 million Hispanic Americans reside. Puerto Rico outperforms the US states and the District of Columbia (“states” hereafter) on some measures of coverage and access,3 but substantial problems with quality of care have been documented.