Nearly Half of Kidney Failure Patients Never Start Transplant Evaluation, Study Finds

For patients with end-stage kidney disease, getting a referral to a transplant center can feel like clearing the hardest hurdle. A new study says it's actually closer to the starting line.

Researchers at NYU Langone Health analyzed records from 720,348 adults referred for kidney transplantation and found that the process filters out most patients long before a surgeon ever gets involved. According to a press release reviewed by PR Newswire, only 19 percent of referred patients completed the full evaluation and landed on the waitlist. Nearly half, 48 percent, never started the evaluation at all.

The study, published June 20 in the Journal of the American Society of Nephrology and presented at the American Transplant Congress, is the largest analysis to date of where patients drop out of the transplant pipeline. Researchers tracked adults from referral through four stages: evaluation, waitlisting, and actual transplant. Only about 10 percent of those initially referred ultimately received a kidney.

The data, drawn from Epic Cosmos, a dataset pulling more than 300 million electronic health records from over 1,850 hospitals, covered more than a third of all U.S. transplant centers. That breadth matters because the study found that which center a patient goes to is itself a risk factor for dropping out.

"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," said lead author Dr. Conor Donnelly, a surgical resident at NYU Grossman School of Medicine, in the PR Newswire release.

The disparities ran across multiple dimensions. Patients who were unmarried, had severe obesity, or lived in rural communities were less likely to start or complete the evaluation. Older adults, Spanish-speaking patients, and those with lower incomes faced even steeper odds. Programs in the Southern United States and smaller transplant centers also showed lower progression rates.

It's worth pausing on what that evaluation actually demands of a sick person. Once a transplant referral is made, patients must complete an extensive battery of tests, including blood work, chest imaging, and cancer screenings, all while attending dialysis sessions several times a week. Patients are added to the waitlist only after clearing every step of that process. For someone without reliable transportation, a support person at home, or a job that accommodates repeated clinic visits, the logistics alone can end a candidacy.

The research team noted that most prior work has focused on outcomes for patients already on the waitlist, leaving this earlier, messier part of the process understudied. As the study authors wrote in the NYU Langone Health release, the findings highlight a need to better support patients between referral and waitlisting, where "many possibly eligible individuals are not ultimately listed."

More than 90,000 Americans are currently on the national kidney transplant waitlist, according to data cited by WDBJ7. That number would almost certainly look different if the evaluation process were more navigable.

Co-senior author Dr. Michal Mankowski, an assistant professor of surgery at NYU Grossman, said the team plans to extend this framework to other organ types, where the path to listing can differ substantially.

The structural message here isn't subtle: a referral is not a guarantee of access. For the majority of patients sent to a transplant center, the system itself becomes the obstacle. Whether transplant programs, insurers, and policymakers treat that as an engineering problem worth solving is the question the data now puts squarely on the table.

Sources cited:
- PR Newswire (NYU Langone Health press release) (https://www.prnewswire.com/news-releases/most-people-seeking-a-kidney-transplant-never-reach-the-waitlist-302799841.html)
- Journal of the American Society of Nephrology (via Medical Xpress) (https://medicalxpress.com/news/2026-06-people-kidney-transplant-waitlist.html)
- HCPLive (https://www.hcplive.com/view/half-referred-patients-reach-kidney-transplant-evaluation)
- WDBJ7 (https://www.wdbj7.com/2026/06/22/hometown-health-most-kidney-failure-patients-never-start-transplant-waitlist-process-study-finds/)
- Medical Update Online (https://medicalupdateonline.com/2026/07/most-people-seeking-a-kidney-transplant-never-reach-the-waitlist/)