OBJECTIVES: Approximately 30% of patients with end-stage kidney disease (ESKD) waitlisted for kidney transplant are highly sensitized against potential donor tissues due to preformed, donor-specific human leukocyte antigens (HLAs) from previous exposure to foreign antigens. Finding a compatible donor for patients with wide ranges of anti-HLA antibodies is extremely difficult. Many highly sensitized patients are unlikely to receive an organ offer placing them at risk of waitlist removal or death on dialysis. In collaboration with patients, advocacy groups and transplant surgeons, a discrete choice experiment was designed to understand the value patients with highly-sensitized ESKD unlikely to be transplanted place on selected attributes of two different therapeutic options: remaining on dialysis or proceeding with an at-risk HLA-incompatible kidney transplant. Understanding the value patients assign to factors associated with continuing dialysis or choosing HLA-incompatible kidney transplant surgery potentially benefits various key stakeholders including reimbursement authorities, healthcare providers involved in high-risk transplants, patient advocacy groups, and most importantly, patients with highly sensitized ESKD.