Half of Kidney Failure Patients Referred for Transplant Never Start the Evaluation Process, Study Finds

For the roughly 90,000 Americans already on the kidney transplant waitlist, the wait is brutal and well-documented. What a new nationwide study makes clear is that the waitlist itself is a finish line most referred patients never reach.

Published June 20 in the Journal of the American Society of Nephrology and presented at the American Transplant Congress, the analysis led by NYU Langone Health researchers is the largest look yet at what happens to kidney failure patients between the moment they're referred for a transplant and the moment, if it ever comes, that they're listed as a candidate.

The numbers are stark. The study examined data from 720,348 patients referred for kidney transplantation. According to findings reported by EurekAlert and confirmed in the journal, nearly half of those patients never began the evaluation process at all, and only 19% completed the assessment and secured a place on the waitlist.

That means the vast majority of people their doctors thought were candidates for a lifesaving procedure never got a real shot at one, not because a donor wasn't available, but because the pipeline broke down long before a donor was ever needed.

"For many kidney failure patients, the biggest obstacle isn't finding a donor, it's making it through the transplant system in the first place," the study authors wrote, according to Science Daily's coverage of the findings.

The researchers didn't just document the dropoff. They tracked who was most likely to fall out. Patients who were unmarried, had severe obesity, or lived in rural communities were less likely to begin or complete a transplant evaluation. Older adults, Spanish speakers, and people with lower incomes faced steeper odds still. Where a patient received care also mattered: those at smaller transplant centers, or at programs located in the South, were less likely to advance through the process.

For a bedside clinician, none of those variables are surprising in isolation. But seeing them quantified together across more than 700,000 patients makes it hard to frame this as a series of individual clinical decisions. These are system failures, playing out at scale.

The timing of the study's publication matters. On July 1, the CMS Increasing Organ Transplant Access Model, known as IOTA, entered its second program year. According to the CMS website, the model currently includes 95 kidney transplant hospitals in a mandatory track, with data-sharing requirements and incentives designed to improve the patient experience and push more referred patients toward listing. IOTA is explicitly built around the idea that transplant access problems exist upstream of the waitlist, the same argument this study now puts hard numbers behind.

What the JASN paper adds is a clearer picture of exactly where the attrition happens and who absorbs it. Nephrology practices, transplant coordinators, and health systems running these programs now have a benchmark. Forty-eight percent of referred patients never even started. That's not a care gap you can close by adjusting a waitlist algorithm.

The study authors said meaningful change will require streamlining referral and evaluation protocols, adding support services, and directing resources toward smaller centers in underserved areas. Those are policy levers, not just clinical ones.

More than 90,000 Americans are currently waiting for a kidney, according to figures cited in media coverage of the study. How many more could have been waiting, and ultimately transplanted, if they'd made it past the front door of the evaluation process is the question this paper forces onto the table.

Sources cited:
- Journal of the American Society of Nephrology (via EurekAlert) (https://www.eurekalert.org/news-releases/1131993)
- Science Daily (https://www.sciencedaily.com/releases/2026/06/260623014006.htm)
- NYU Langone Health / PR Newswire (https://www.prnewswire.com/news-releases/most-people-seeking-a-kidney-transplant-never-reach-the-waitlist-302799841.html)
- CMS IOTA Model (https://www.cms.gov/priorities/innovation/innovation-models/iota)
- WDBJ7 / Hometown Health (https://www.wdbj7.com/2026/06/22/hometown-health-most-kidney-failure-patients-never-start-transplant-waitlist-process-study-finds/)