By Hendra Lukman 
A groundbreaking nationwide study has unveiled a stark reality for individuals battling kidney failure: a significant portion of those referred for a kidney transplant never even embark on the crucial evaluation process. The research, published in the Journal of the American Society of Nephrology, reveals that nearly half of these patients fall out of the pathway before initiating the necessary steps to be considered for a life-saving donor organ. Even more concerning, fewer than one in five successfully complete the comprehensive evaluation and secure a coveted spot on the transplant waitlist.
This comprehensive analysis, spearheaded by researchers at NYU Langone Health, delved into the electronic health records of over 720,000 patients referred for kidney transplantation between 2014 and 2025. The findings paint a concerning picture of systemic barriers and disparities that prevent many desperately ill patients from accessing a potentially life-altering procedure. While much of the public discourse and medical attention surrounding kidney transplantation focuses on patients already on the waitlist, this study shines a critical light on the often-overlooked "pre-waitlist" phase, identifying where and why so many individuals are being left behind.
Unpacking the Major Barriers to Kidney Transplant Waitlisting
The study’s findings are striking in their revelation of significant disparities in who progresses through the kidney transplant evaluation process. The research identified several key demographic and socioeconomic factors that demonstrably hinder a patient’s journey toward the waitlist.
Patients who were unmarried, struggled with severe obesity, or resided in rural communities were found to be significantly less likely to initiate or complete the transplant evaluation. The challenges escalated for older adults, Spanish speakers, and individuals with lower incomes, who faced even greater obstacles. Furthermore, the geographic location of care played a crucial role. Patients receiving treatment at smaller transplant centers or those situated in programs within the Southern United States were also less likely to advance through the evaluation stages.
"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," stated study lead author Conor Donnelly, MD, a resident and PhD student in the Department of Surgery at NYU Grossman School of Medicine. "Which transplant center you go to, where you live, and even whether you are married all appear to influence your chances of moving forward to the waitlist for a new kidney."
The overall statistics are sobering: only 19% of all referred patients successfully navigated the entire evaluation process and were placed on the transplant waitlist. In stark contrast, a staggering 48% never even commenced the evaluation, representing a substantial loss of potentially viable candidates.
The Intricate and Demanding Nature of Transplant Evaluation
Dr. Donnelly posits that the inherent complexity and demanding nature of the transplant evaluation process itself likely contribute significantly to the observed variations in patient progression. Following a referral, individuals are subjected to an extensive medical assessment designed to gauge their overall health and suitability for a major surgical procedure and lifelong immunosuppression. This rigorous evaluation typically encompasses a battery of blood tests, diagnostic imaging such as chest X-rays, comprehensive cancer screenings, and a multitude of other examinations.
The process is not a one-time event; it often necessitates multiple appointments spread over several months. This extended timeline occurs while patients are simultaneously managing their ongoing, often debilitating, regular dialysis treatments. Only after successfully meeting all these stringent requirements and receiving explicit approval from the transplant team can a patient officially be added to the coveted kidney transplant waitlist.
The researchers also highlighted potential systemic issues at play. Smaller transplant centers, which may operate with fewer resources and a more limited volume of transplant opportunities, might adopt a more selective approach in their candidate evaluations. This selectivity, while perhaps driven by resource constraints, can inadvertently create additional hurdles for patients.
Moreover, the study underscored the significant impact of social support networks. Patients who are unmarried or lack robust social support may encounter greater difficulties in arranging transportation for numerous appointments, coordinating care, and managing the logistical demands of the evaluation. This challenge is particularly pronounced for individuals living in urban areas where transplant centers are often more accessible. However, the study’s data indicated that urban dwellers were generally more likely to continue through the process, suggesting that while access might be a factor, other interconnected social and economic determinants of health are at play.
The Largest Examination of Kidney Transplant Dropout Rates to Date
Published online on June 20th in the prestigious Journal of the American Society of Nephrology, this research stands as the largest and most detailed study to date that meticulously examines the points at which patients depart from the kidney transplant pathway before reaching the waitlist. The findings are also being presented at the American Transplant Congress, the premier annual gathering jointly organized by the American Society of Transplantation and the American Society of Transplant Surgeons, underscoring their significance within the transplant community.
To conduct this pivotal analysis, the research team leveraged Epic Cosmos, a vast and comprehensive database that aggregates electronic health records from over 1,850 hospitals across the United States. This database contains the medical information of more than 300 million individuals, crucially including data from over one-third of all U.S. transplant centers. This extensive data pool allowed for an unprecedented granular view of patient journeys.
The team meticulously tracked adults who were referred for kidney transplantation between the years 2014 and 2025. Each patient’s trajectory was monitored through four distinct stages: referral, evaluation, waitlist, and ultimately, transplant. This longitudinal approach provided a clear picture of attrition at each critical juncture.
Social Determinants and Geographic Factors Critically Influence Outcomes
Employing sophisticated statistical modeling, the researchers rigorously evaluated how a wide array of factors – including age, sex, pre-existing medical conditions, and geographic location – influenced a patient’s likelihood of progressing from one stage of the transplant process to the next.
A significant focus was placed on assessing "social vulnerability." This metric encapsulates the challenges individuals face related to their living conditions and access to essential healthcare services. Factors such as poverty, housing instability, and limited transportation options were identified as key contributors to difficulties in navigating the complex and often arduous medical system.
"These results demonstrate that finding ways to reduce barriers to both evaluation and waitlisting could help expand much-needed access to kidney transplantation," emphasized study co-senior author Allan B. Massie, PhD, an associate professor in the Departments of Surgery and Population Health at NYU Grossman School of Medicine. "Providing patients with better education and support to help them navigate the complex and sometimes grueling process would be a good start."
Echoing this sentiment, study co-senior author Michal A. Mankowski, PhD, an assistant professor in the Department of Surgery at NYU Grossman School of Medicine, stated, "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."
Dr. Mankowski further indicated that future research endeavors will employ a similar analytical framework to investigate other types of organ transplantation. This comparative approach is crucial, as the pathways to waitlisting can differ significantly across various organ systems.
Broader Implications and the Path Forward
The implications of this study are far-reaching and demand urgent attention from healthcare providers, policymakers, and transplant centers alike. The substantial attrition rate before patients even reach the waitlist suggests a systemic failure to adequately support vulnerable populations in accessing essential medical care.
The findings underscore the critical need for a multifaceted approach to address these disparities. This could include:
- Enhanced Patient Navigation and Support: Implementing dedicated patient navigators who can assist individuals in understanding the evaluation process, scheduling appointments, and addressing logistical challenges. This support is particularly crucial for those with limited social support or language barriers.
- Culturally Competent Care: Ensuring that transplant centers offer services in multiple languages and are sensitive to cultural nuances that may impact patient engagement and adherence.
- Streamlined Evaluation Processes: Exploring ways to simplify and expedite the evaluation process without compromising patient safety or the integrity of the assessment. This might involve greater use of telehealth for initial consultations or integrating evaluation components with existing dialysis care.
- Targeted Outreach and Education: Developing proactive outreach programs to educate patients with kidney failure about the importance of transplant evaluation and to demystify the process.
- Addressing Social Determinants of Health: Collaborating with community organizations and social services to address underlying issues such as transportation, housing, and financial instability that can impede access to care.
- Center-Specific Quality Improvement Initiatives: Encouraging transplant centers, particularly smaller ones or those in underserved regions, to critically examine their evaluation protocols and identify areas for improvement in patient retention.
The study’s co-authors, including 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 from NYU Langone, along with collaborators Rachel Patzer, PhD, MPH, of Indiana University and David Axelrod, MD, of University Hospitals, have provided a vital roadmap for future research and policy interventions. The recognition of Dr. Orandi’s advisory board role for Boehringer Ingelheim and NYU Langone Health’s management of this relationship highlight the complex landscape of research funding and potential conflicts of interest, while reaffirming the independent nature of the study’s findings.
Ultimately, the NYU Langone Health-funded study serves as a critical call to action. By shedding light on the significant drop-off points in the kidney transplant pathway, it empowers the medical community to implement targeted strategies that ensure more individuals in need receive the life-saving opportunity of a transplant. The goal is not merely to increase waitlist numbers, but to ensure equitable access to a treatment that can profoundly improve and extend lives. The journey from referral to transplant is a complex one, and this research illuminates the urgent need to make that journey more accessible and navigable for all.
