Nearly Half of Kidney Transplant Candidates Never Begin Evaluation, Landmark Study Finds
核心洞察
A national study of 720,348 referred patients found that 48% never started the transplant evaluation process, and only 19% ultimately reached the waitlist.
Unmarried, older, Spanish-speaking, rural, and lower-income patients were disproportionately likely to drop out before completing evaluation.
Smaller transplant centers and programs in the southern United States showed lower rates of patient progression to the waitlist.
A comprehensive national study has revealed that nearly half of Americans with kidney failure (搜索) who are referred for transplantation never begin the evaluation process required to be considered for a new organ, while fewer than one in five ultimately complete the assessment and secure a place on the national waitlist.
Led by researchers at NYU Langone Health, the study analyzed data from 720,348 adults referred for kidney transplant between 2014 and 2025, drawing on the Epic Cosmos dataset, which encompasses more than 300 million electronic health records from over 1,850 hospitals, including more than a third of all U.S. transplant centers. The findings were published June 20 in the Journal of the American Society of Nephrology and presented simultaneously at the American Transplant Congress.
"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 Conor Donnelly, MD, study lead author and a resident and PhD 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."
Stark Dropout Rates Across the Transplant Pipeline
The study tracked patients through four sequential stages: referral, evaluation, waitlist, and transplant. The results were striking: only 19% of referred patients completed the evaluation and were placed on the waitlist, while 48% never even started the evaluation process.
Much of this attrition may stem from the complexity of the transplant evaluation itself. Once a referral is made, patients must undergo a battery of tests—including blood work, chest imaging, and cancer screenings—often requiring multiple visits over several months while simultaneously attending dialysis sessions each week. Only after completing this process and receiving approval are candidates placed on the waitlist.
Disparities by Demographics, Geography, and Center Size
Using statistical models, the researchers analyzed how a wide range of factors affected the likelihood of progressing from one step to the next. They found that patients who were unmarried, had severe obesity, or lived in rural areas were less likely to start or complete an evaluation. Older, Spanish-speaking, and poorer patients were especially unlikely to progress, as were those treated at smaller transplant centers or at programs in the South.
The researchers also examined social vulnerability—a measure of how living conditions such as poverty, lack of transportation, and unstable housing may disadvantage patients seeking care. Smaller centers with fewer resources and transplant slots may be more selective and risk-averse than larger programs, the authors noted. Candidates who lack strong social support may struggle to make repeated trips for evaluations and follow-up appointments, which may help explain why urban patients, who have more numerous and closer transplant centers, are more likely to move forward.
A Call for Systemic Improvements
"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, 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."
Study co-senior author Michal A. Mankowski, PhD, assistant professor in the Department of Surgery at NYU Grossman School of Medicine, 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."
Dr. Mankowski noted that 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.
The study is the largest and most detailed to date examining where patients drop out of the kidney transplant process. While previous research has focused extensively on outcomes after waitlisting, this work shifts attention to an earlier and arguably more consequential barrier: the gap between referral and even beginning the evaluation.
NYU Langone Health provided funding for the study. Dr. Orandi, one of the study co-investigators, has served on an advisory board for Boehringer Ingelheim, with NYU Langone Health managing the terms and conditions of this relationship in accordance with its policies.