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The Southeastern region of the United States has the highest burden of end-stage renal disease (ESRD) but the lowest rates of kidney transplantation in the nation. There are many patient-, dialysis facility–, ESRD Network– and health system–level barriers that contribute to this regional disparity. Compared to the rest of the nation, the Southeast has a larger population of African-Americans and higher poverty, as well as more prevalent ESRD risk factors including hypertension, obesity and diabetes. Dialysis facilities—where ESRD patients receive the majority of their healthcare—play an important role in transplant access. Identifying characteristics of individual dialysis units with low rates of kidney transplantation, such as understaffing or for-profit status, can help identify targets for quality improvement initiatives. Geographic differences across the country can identify opportunities to increase funding for healthcare resources in proportion to patient and disease burden. Focusing interventions among dialysis facilities with the lowest transplant rates within the Southeast, such as provider and patient education, has the potential to increase referrals for kidney transplantation, leading to higher rates of kidney transplants in this region. Referral for transplantation should be measured on a national level to monitor disparities in early access to transplantation. Transplant centers have an obligation to assist underserved populations in ensuring equity in access to services. Policies that improve access to care for patients, such as the Affordable Care Act and Medicaid expansion, are particularly important for Southern states and may alleviate geographic disparities.