By Hendra Lukman 
A groundbreaking nationwide study has unveiled a deeply concerning trend within the organ transplant system: a significant portion of Americans suffering from kidney failure, who are referred for a potential life-saving kidney transplant, never even begin the crucial evaluation process. The research, conducted by leading experts at NYU Langone Health, indicates that a staggering 48% of these patients fall out of the pathway before their candidacy can be assessed. Even more alarming, fewer than one in five (19%) successfully navigate the entire evaluation and secure a coveted spot on the national transplant waitlist. This research, published online in the Journal of the American Society of Nephrology, represents the most comprehensive analysis to date of patient attrition at the pre-waitlist stages of kidney transplantation.
The findings underscore a critical gap in understanding and addressing the barriers faced by patients before they reach the transplant waitlist, a phase that has historically received less attention than post-waitlist care. Researchers emphasized that while much focus is placed on patients once they are on the waitlist, the journey to that point is fraught with obstacles that prevent many from even starting the process.
Unveiling Significant Disparities in Transplant Access
The extensive study analyzed data from a colossal 720,348 patients referred for kidney transplantation between 2014 and 2025, utilizing the vast Epic Cosmos database, which encompasses electronic health records from over 1,850 hospitals across the United States, including more than a third of all transplant centers. This comprehensive dataset allowed researchers to meticulously track patients through four distinct stages: referral, evaluation, waitlist placement, and ultimately, transplant.
The analysis revealed stark disparities in who is able to progress through the rigorous transplant evaluation process. Several demographic and socioeconomic factors were identified as significant predictors of whether a patient would initiate or complete the evaluation and subsequently be placed on the waitlist.
Patients who were unmarried, had severe obesity, or resided in rural communities demonstrated a lower likelihood of starting or completing a transplant evaluation. The challenges were even more pronounced for older adults, Spanish speakers, and individuals with lower incomes. Furthermore, the geographical location of care and the size of the transplant center played a discernible role. Patients receiving treatment at smaller transplant centers or those located in the Southern United States were also less likely to advance in the transplant pipeline.
"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 Dr. Conor Donnelly, the study’s lead author and 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."
Dr. Donnelly’s co-senior authors, Dr. Allan B. Massie, an associate professor in the Departments of Surgery and Population Health at NYU Grossman School of Medicine, and Dr. Michal A. Mankowski, an assistant professor in the Department of Surgery at NYU Grossman School of Medicine, echoed these sentiments. Dr. Massie emphasized, "These results demonstrate that finding ways to reduce barriers to both evaluation and waitlisting could help expand much-needed access to kidney transplantation. Providing patients with better education and support to help them navigate the complex and sometimes grueling process would be a good start." Dr. Mankowski added, "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."
The Labyrinthine Nature of the Transplant Evaluation Process
The complexity inherent in the kidney transplant evaluation process is a significant contributing factor to the observed attrition rates, according to Dr. Donnelly. Following a referral, potential recipients must undergo an exhaustive medical assessment to determine their overall health and suitability for a transplant. This typically involves a battery of tests, including extensive blood work, chest imaging, cancer screenings, and other specialized examinations. The entire process can span several months and necessitates multiple appointments, often while patients are concurrently undergoing regular dialysis treatments, a demanding regimen in itself.
Only after successfully completing these stringent requirements and receiving approval from the transplant team can a patient be formally added to the national kidney transplant waitlist. This arduous journey, laden with medical hurdles and logistical demands, presents a formidable challenge for many individuals already grappling with the debilitating effects of kidney failure.
The study also shed light on potential reasons behind the disparities observed across different transplant centers. Smaller transplant centers, which may operate with fewer resources and a lower volume of transplant opportunities, might adopt a more selective approach in their candidate evaluations. This could inadvertently create higher barriers for patients seeking care at these institutions.
Furthermore, social support networks appear to play a crucial role. Patients who are unmarried or lack robust social support may encounter greater difficulties in arranging transportation to and from multiple appointments, coordinating with healthcare providers, and managing the overall demands of the evaluation. This is particularly relevant for patients living in urban areas, where transplant centers are often more concentrated and accessible, compared to those in rural settings where travel can be a substantial obstacle.
A Landmark Study on Pre-Waitlist Attrition
The research, presented at the prestigious American Transplant Congress, the annual meeting jointly organized by the American Society of Transplantation and the American Society of Transplant Surgeons, is distinguished by its sheer scale and detailed examination of patient drop-off rates prior to waitlisting.
The methodology employed involved leveraging the Epic Cosmos database, a colossal repository of electronic health records from over 1,850 hospitals. This provided an unprecedented view into the patient journey across a diverse range of healthcare settings and transplant programs. The study’s temporal scope, spanning from 2014 to 2025, allowed for the analysis of trends and the impact of various factors over more than a decade.
Socioeconomic and Geographic Determinants of Transplant Access
Employing sophisticated statistical modeling, the research team meticulously evaluated how a wide array of factors, including age, sex, medical history, and geographic location, influenced a patient’s probability of progressing from one stage of the transplant process to the next.
A key aspect of the analysis focused on "social vulnerability," a measure that quantifies the challenges individuals face due to their living conditions and access to essential services. This includes indicators such as poverty, housing instability, and limited transportation options, all of which can significantly impede a person’s ability to navigate complex healthcare systems and adhere to demanding treatment protocols.
The implications of these findings are profound. For every patient who successfully makes it onto the waitlist, several potentially eligible candidates are being lost along the way. This not only represents a missed opportunity for individual patients to receive a life-saving organ but also contributes to the growing demand for kidney transplants and the ongoing challenge of organ shortages.
The study’s authors suggest that a multi-pronged approach is necessary to address these systemic issues. Enhanced patient education tailored to the specific needs and challenges of individuals facing kidney failure is crucial. This education should extend beyond medical information to encompass practical guidance on navigating the evaluation process, accessing resources, and building support systems.
Moreover, increased investment in patient support services, including transportation assistance, social work interventions, and patient advocacy programs, could significantly mitigate some of the barriers identified. For transplant centers, particularly smaller ones, exploring collaborative models and resource-sharing initiatives might enhance their capacity to evaluate and manage a broader range of candidates.
Dr. Mankowski indicated that future research will expand upon this methodology to investigate similar pre-waitlist attrition patterns in other types of organ transplantation, recognizing that the pathways to transplantation can vary considerably.
The research team involved in this seminal study comprises a robust group of experts from NYU Langone Health, 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. Additional collaborators from other institutions include Rachel Patzer, PhD, MPH, of Indiana University and David Axelrod, MD, of University Hospitals.
Dr. Orandi has disclosed a relationship with Boehringer Ingelheim, serving on an advisory board, with NYU Langone Health managing the terms and conditions of this association. The study itself was funded by NYU Langone Health.
The stark reality presented by this research calls for urgent attention from healthcare providers, policymakers, and patient advocacy groups to ensure that every individual with kidney failure has a equitable opportunity to be considered for a life-altering kidney transplant. The current system, as illuminated by this study, is failing a significant number of those who need it most.
