There are clear and compelling racial disparities in access to renal transplant, which is the therapy of choice for many patients with end stage renal disease. This paper conceptualizes the role of racism (i.e., internalized, personally-mediated, and institutionalized) in creating and perpetuating these disparities at multiple levels of the social ecology by integrating two often-cited theories in the literature. Internalized racism is Manifested at the intrapersonal level when, for example, African American patients devalue their self-worth, thereby not pursuing the most aggressive treatment available. Personally-mediated racism is manifested at the interpersonal level when, for example, physicians exhibit unconscious race bias that impacts their treatment decisions. One example of institutionalized racism being manifested at the institutional, community, and public policy levels is the long-standing existence of racial residential segregation and empirically established links between neighborhood racial composition and dialysis facility-level transplantation rates. This paper concludes with clinical, research, and policy recommendations.