There is considerable variation in the prevalence of end-stage kidney disease (ESKD) and the number of kidney transplants performed across the United States. A regional epidemiological approach was taken to investigate why there was a discrepancy between the prevalence of ESKD and the number of kidney transplants performed. From 2015-2017, incident ESKD and kidney transplants per 1,000 incident ESKD cases in the US were evaluated using data from the US Renal Data System. County health scores were shown to be linked with local Moran’s I estimates of the clustering of ESKD burden and kidney transplant rates at the county level. The general health of a county was worse if the percentile score was higher. Clusters with high ESKD burdens were often located near areas with low kidney transplant rates and vice versa. For the most prevalent cluster type, the incidence of ESKD and the frequency with which transplants were performed were high, but the latter was less common (377 counties). These clusters contained the counties with the greatest average ESKD incidence (61.3), the lowest average transplant rate (61.1%), and the highest average percentile for county health scores (80.9%, P<0.001 vs. all other cluster types). Comparatively, the counties that were part of clusters with low ESKD incidence and high transplant rates (n=359) had the greatest mean transplant rate (110.6), the lowest mean ESKD incidence (28.9%), and the lowest county health scores (20.2%). All contrasts with high-ESKD/low-transplant clusters were statistically significant (P<0.001). There was a major discrepancy between kidney transplant rates and the prevalence of ESKD; the rates were lowest in regions with the highest need. As seen by the study’s highest county health scores, this trend worsens existing inequalities, as economically depressed areas with high rates of ESKD have poorer access to care and overall community health.