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End-stage renal disease (ESRD) and poverty are highly prevalent conditions in the Southeastern United States. The American Southeast also has some of the lowest attainments of health status among its constituents. Transplantation rates are particularly low in the Southeast compared with other regions of the United States. These low kidney transplantation rates in the Southeast likely reflect poor access to medical care. This disproportionate lack of access to medical care among ESRD patients in the Southeast reflects the convergence and interaction of socioeconomic and biologic forces at the patient level interacting with the financial and organizational structure of the health-care system. Improving kidney transplant access in the Southeast will take disruptive political, financial and health system changes whose scope transcends transplant centers and dialysis units., (© Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons.)