A national study reveals that almost half of kidney failure patients referred for transplants do not start the evaluation process, with only 19% making it to the waitlist.
New Delhi, India Jul 2, 2026 ALN: Nearly half of Americans with kidney failure who are referred for a kidney transplant never begin the evaluation process required to be considered for a donor organ, according to a new nationwide study. Even more striking, fewer than one in five complete the evaluation and secure a place on the transplant waitlist. This alarming statistic raises questions about the accessibility and efficiency of the kidney transplant system in the United States, a system that is already under strain due to the growing number of patients with end-stage renal disease.
Researchers say much attention has been given to patients after they reach the waitlist, but far less is known about what happens before that point and why so many people never make it there. Understanding the barriers that prevent patients from advancing through the evaluation process is crucial for improving outcomes and ensuring that those in need of transplants receive timely and equitable care.
The study, led by researchers at NYU Langone, analyzed data from 720,348 patients referred for kidney transplantation. The findings revealed significant disparities in who advances through the process. Patients who were unmarried, had severe obesity, or lived in rural communities were less likely to begin or complete a transplant evaluation and ultimately reach the waitlist. Older adults, Spanish speakers, and people with lower incomes faced even greater challenges. Patients receiving care at smaller transplant centers or programs located in the Southern United States were also less likely to move forward.
Overall, just 19% of referred patients completed the evaluation process and were placed on the waitlist, while 48% never started the evaluation at all. This highlights a critical gap in the care continuum for patients with kidney failure, who often face a complicated and lengthy process to secure a transplant.
"Our findings suggest that a substantial proportion of people who need a new kidney fall out of the process long before they reach the waitlist, let alone make it to the operating room," said study lead author Conor Donnelly, MD.
Donnelly is a resident and PhD student in the Department of Surgery at NYU Grossman School of Medicine. His insights underscore the necessity of addressing the barriers that prevent patients from progressing through the kidney transplant pathway.
According to Donnelly, the complexity of the transplant evaluation process may explain much of the variation seen in the study. After receiving a referral, patients must complete an extensive medical assessment designed to evaluate their overall . This often includes blood tests, chest imaging, cancer screenings, and other examinations. The process may require multiple appointments over several months while patients continue attending regular dialysis treatments.
Only after completing these requirements and receiving approval can a patient be added to the transplant waitlist. The extensive nature of this evaluation can be overwhelming for many patients, especially those who may already be struggling with the physical and emotional toll of kidney failure. Additionally, the need for multiple appointments can create logistical challenges, particularly for those who lack reliable transportation or support systems.
Researchers noted that smaller transplant centers may have fewer resources and available transplant opportunities, which could lead them to be more selective when evaluating candidates. They also pointed out that patients who are unmarried or have limited social support may face greater difficulties arranging transportation and attending repeated appointments. These factors may help explain why patients living in urban areas, where transplant centers are often more accessible, were generally more likely to continue through the process.
Published online June 20 in the Journal of the American Society of Nephrology, the research is the largest and most detailed study to date examining where patients leave the kidney transplant pathway before reaching the waitlist, according to the authors. This comprehensive examination sheds light on a critical issue that has implications for public and care policy.
The findings are also being presented at the American Transplant Congress, the annual meeting jointly organized by the American Society of Transplantation and the American Society of Transplant Surgeons. The visibility of this research at such a prominent forum highlights the urgency of addressing the barriers identified in the study.
To conduct the analysis, researchers used Epic Cosmos, a database containing more than 300 million electronic records from over 1,850 hospitals, including more than one-third of US transplant centers. This extensive dataset allowed researchers to track a diverse population of patients referred for kidney transplantation, providing a comprehensive picture of the challenges faced by individuals at various stages of the transplant process.
The team examined adults referred for kidney transplantation between 2014 and 2025. Each patient was tracked through four stages: referral, evaluation, waitlist, and transplant. This longitudinal approach enables a deeper understanding of the factors that contribute to dropout rates at each stage.
Using statistical modeling, the researchers evaluated how factors such as age, sex, medical history, and geographic location affected the likelihood of advancing from one stage to the next. This analysis revealed that social vulnerability, which reflects challenges related to living conditions and access to care, plays a significant role in determining whether individuals are able to navigate the transplant process.
Examples of social vulnerability include poverty, unstable housing, and limited transportation options, all of which can make navigating complex medical systems more difficult. These findings underscore the importance of considering social determinants of in the context of kidney transplantation, as they can significantly impact patient outcomes.
"These results demonstrate that finding ways to reduce barriers to both evaluation and waitlisting could help expand much-needed access to kidney transplantation," said study co-senior author Allan B. Massie, PhD.
Massie is an associate professor in the Departments of Surgery and Population at NYU Grossman School of Medicine. His comments reflect a growing recognition of the need to address systemic inequities in care access, particularly for vulnerable populations.
"Our findings highlight the need to better support patients in progressing from referral to the waitlist, where many possibly eligible individuals are not ultimately listed," said study co-senior author Michal A. Mankowski, PhD. Mankowski, an assistant professor in the Department of Surgery at NYU Grossman School of Medicine, emphasized the importance of future research aimed at identifying effective interventions to improve access to transplantation.
Future research will apply a similar approach to other types of organ transplantation, where the path to the waitlist can differ significantly. By understanding the unique challenges faced by patients in different organ transplant programs, researchers hope to develop targeted strategies to improve outcomes across the board.
Additional NYU Langone researchers involved in the project included Suhani Patel, MPH; Syed Ali Husain, MD, MPH; Sommer E. Gentry, PhD; Bonnie E. Lonze, MD, PhD; Sunjae Bae, MD, PhD; Babak J. Orandi, MD, PhD; Mara A. McAdams DeMarco, PhD; and Dorry L. Segev, MD, PhD.
NYU Langone funded the study.
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