Numerous factors impact patients' health beyond traditional clinical characteristics. We evaluated the association of risk factors in kidney transplant patients' communities with outcomes prior to transplantation. The primary exposure variable was a community risk score (range 0–40) derived from multiple databases and defined by factors including prevalence of comorbidities, access and quality of healthcare, self-reported physical and mental health and socioeconomic status for each U.S. county. We merged data with the Scientific Registry of Transplant Recipients (SRTR) and utilized risk-adjusted models to evaluate effects of community risk for adult candidates listed 2004–2010 (n = 209 198). Patients in highest risk communities were associated with increased mortality (adjusted hazard ratio [AHR] = 1.22, 1.16–1.28), decreased likelihood of living donor transplantation (adjusted odds ratio [AOR] = 0.90, 0.85–0.94), increased waitlist removal for health deterioration (AHR = 1.36, 1.22–1.51), decreased likelihood of preemptive listing (AOR = 0.85, 0.81–0.88), increased likelihood of inactive listing (AOR = 1.49, 1.43–1.55) and increased likelihood of listing for expanded criteria donor kidneys (AHR = 1.19, 1.15–1.24). Associations persisted with adjustment for rural–urban location; furthermore the independent effects of rural–urban location were largely eliminated with adjustment for community risk. Average community risk varied widely by region and transplant center (median = 21, range 5–37). Community risks are powerful factors associated with processes of care and outcomes for transplant candidates and may be important considerations for developing effective interventions and measuring quality of care of transplant centers.