Most People Seeking a Kidney Transplant Never Reach the Waitlist

Note: This presentation at American Transplant Congress on Saturday, June 20, at 4:30 p.m. ET in Boston, Massachusetts, is titled ""Individual and Center Level Determinants of Progression from Kidney Transplant Referral to Kidney Transplantation in the United States: A National EHR Study" and is part of the Emerging Discoveries Oral Abstract Sessions.

Reducing barriers in the evaluation process may improve access to lifesaving procedures

NEW YORK, June 20, 2026 /PRNewswire/ -- 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 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 percent of referred patients completed the evaluation, and 48 percent never even started it.

"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. "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 is a resident and PhD student in NYU Grossman School of Medicine's Department of Surgery.

Much of this variation may stem from the complexity of the process, which can be difficult for patients to navigate, said Dr. Donnelly. 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.

Publishing online June 20 in the Journal of the American Society of Nephrology, 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 dataset of more than 300 million electronic health records from over 1,850 hospitals, including more than a third of all US 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.

"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, 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, PhD.

Dr. 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.

NYU Langone Health provided funding for the study.

Along with Drs. Donnelly, Massie, and Mankowski, NYU Langone researchers involved in the study were 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. Other study co-investigators were Rachel Patzer, PhD, MPH, at Indiana University in Indianapolis, and David Axelrod, MD, at University Hospitals in Cleveland. 

Dr. Orandi has served on an advisory board for the pharmaceutical company Boehringer Ingelheim. NYU Langone Health is managing the terms and conditions of this relationship in accordance with its policies and procedures.
 

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About NYU Langone Health

NYU Langone Health is a fully integrated health system that consistently achieves the best patient outcomes through a rigorous focus on quality that has resulted in some of the lowest mortality rates in the nation. Vizient, Inc. has ranked NYU Langone No. 1 out of 118 comprehensive academic medical centers across the nation for four years in a row, and U.S. News & World Report recently ranked four of its clinical specialties number one in the nation. NYU Langone offers a comprehensive range of medical services with one high standard of care across seven inpatient locations, its Perlmutter Cancer Center, and more than 320 outpatient locations in the New York area and Florida. The system also includes two tuition-free medical schools, in Manhattan and on Long Island, and a vast research enterprise.

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SOURCE NYU Grossman School of Medicine and NYU Langone Health