Most people seeking a kidney transplant in the US never reach the waitlist
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Nearly half of Americans with kidney failure who are referred for transplantation never begin the process required to be considered for a new organ, a new study shows, while less than a fifth actually complete the assessment and get on the waitlist. While experts have studied what happens once people make it onto the list, little attention has been paid to challenges in making the waitlist in the first place, the study authors said.
Led by NYU Langone Health researchers, the national study of 720,348 patients referred for the procedure, which appears in the Journal of the American Society of Nephrology, found that those who were unmarried, had severe obesity, or lived in rural areas were less likely to start or complete an evaluation at a transplant center and make the waitlist. Older, Spanish-speaking and poorer patients were especially unlikely to progress, as were those treated at smaller centers or at programs in the South. Results showed that only 19% of referred patients completed the evaluation, and 48% never even started it.
Where patients fall behind
"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, a resident and Ph.D. student in NYU Grossman School of Medicine's Department of Surgery. "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."
Much of this variation may stem from the complexity of the process, which can be difficult for patients to navigate, Donnelly said. Once a referral for a kidney transplant is made, the patient undergoes a battery of tests to provide a detailed picture of their health. These tests may include blood work, chest imaging and cancer screenings, often requiring the patient to make several visits over a period of months while also attending dialysis sessions each week. Only after this process is completed and the candidate is approved are they placed on the waitlist.
Smaller centers with fewer resources and transplant slots may be more selective and risk-averse than larger programs, the researchers said. Also, candidates who are unmarried or lack strong social support may struggle to make repeated trips for evaluations and follow-up appointments. This may help explain why people living in urban areas, where transplant centers are more numerous and often closer to home, are more likely to move forward in the process.
Tracking the transplant pipeline
The study is the largest and most detailed to date to examine where patients drop out of the kidney transplant process, according to the authors. It is simultaneously being presented at the American Transplant Congress, the annual joint meeting of the American Society of Transplantation and the American Society of Transplant Surgeons.
For the study, the team used Epic Cosmos, a data set of more than 300 million electronic health records from more than 1,850 hospitals, including more than a third of all U.S. transplant centers. The researchers focused on adults referred for a kidney transplant between 2014 and 2025, tracking each patient through four stages: referral, evaluation, waitlist and transplant.
Using statistical models, the researchers analyzed how a wide range of factors, from age and sex to geographic location and medical history, affected the chance of moving from one step to the next. They also examined social vulnerability—a measure of how a person's living conditions, such as poverty, lack of transportation and unstable housing, may disadvantage them when they're trying to get care.
Support beyond the referral
"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, Ph.D., 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."
"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, Ph.D.
Mankowski, an assistant professor in the Department of Surgery at NYU Grossman School of Medicine, said the team next plans to extend this research approach to other types of organ transplants, for which the path to the waitlist can look very different.
Publication details
Evaluating Barriers to Kidney Transplantation in the United States, Journal of the American Society of Nephrology (2026).
Journal information: Journal of the American Society of Nephrology
Key medical concepts
Kidney Failure, ChronicKidney TransplantationSocial Vulnerability Index
Clinical categories
NephrologyCommon illnesses & Prevention Provided by NYU Langone Health Who's behind this story?
Stephanie Baum
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