Nearly half never took the first step.
Each year, hundreds of thousands of Americans with kidney failure are referred toward a transplant that most will never receive — not because medicine cannot help them, but because the path between referral and waitlist is long, complex, and unevenly navigated. A landmark study tracking over 720,000 patients finds that nearly half never begin the evaluation process, and fewer than one in five complete it, with outcomes shaped less by medical need than by geography, language, marital status, and the size of one's nearest transplant center. The research, drawn from over 1,850 hospitals across more than a decade, illuminates a quiet crisis in which systemic architecture — not illness alone — determines who receives a second chance at life.
- A national study reveals that 48% of kidney transplant referrals go nowhere — patients disappear from the pipeline before a single evaluation step is taken.
- The evaluation process itself is a months-long gauntlet of blood work, imaging, cancer screenings, and repeated clinic visits, all while patients continue dialysis — a burden that breaks many before they begin.
- Unmarried patients, rural residents, Spanish-speakers, the elderly, those in poverty, and those assigned to smaller transplant centers all face measurably steeper odds of progressing toward the waitlist.
- Smaller transplant programs, stretched thin on staff and resources, become more selective and risk-averse — quietly narrowing access for the very patients who may need the most support.
- Researchers are now calling for streamlined evaluation pathways and stronger patient navigation systems, arguing that thousands of medically eligible candidates are being lost to structural friction, not clinical failure.
Nearly half of Americans referred for a kidney transplant never take the first step toward one. A sweeping study from NYU Langone Health, tracking more than 720,000 patients referred between 2014 and 2025, found that only 19 percent completed the full evaluation process and reached the transplant waitlist. The rest fell away — most of them before the process even began.
The evaluation is formidable. Patients must complete extensive blood work, imaging, and cancer screenings across months of appointments, all while attending regular dialysis. For those without reliable transportation, a supportive partner, or proximity to a transplant center, the process becomes nearly impossible to sustain. The study found that unmarried patients, those with severe obesity, rural residents, older patients, Spanish-speakers, and those living in poverty all showed significantly lower rates of progression through each stage.
Where a patient receives care matters enormously. Smaller transplant centers, with fewer staff and fewer available slots, tend to be more selective — and programs in the South showed particularly low completion rates. As lead author Dr. Conor Donnelly noted, factors like which center you attend, where you live, and whether you are married all appear to shape your chances of ever reaching the waitlist.
The researchers, drawing on over 300 million electronic health records from more than 1,850 hospitals, argue that the system itself is filtering out eligible patients before they receive a fair evaluation. Co-senior author Dr. Allan Massie called for improved patient education and navigation support to help people move through what he described as a complex and sometimes grueling process. The team plans to extend the research to other organ transplants. Their central finding is difficult to set aside: the barrier for most of these patients is not medical — it is structural.
Nearly half of Americans referred for a kidney transplant never actually begin the evaluation process that would put them on the waitlist for a new organ. That's the finding of a sweeping national study that tracked over 720,000 patients through the transplant pipeline, revealing a stark gap between who gets referred and who ever makes it to surgery. Only 19 percent of those referred completed the full evaluation and landed on the waitlist. The rest—nearly half—never took the first step.
Researchers at NYU Langone Health, publishing their findings in the Journal of the American Society of Nephrology, say this dropout happens long before patients reach the operating room, and it's not random. Geography matters. Marital status matters. Whether you speak Spanish or English matters. Where you live—urban or rural—shapes your odds. So does the size of the transplant center you're assigned to. The study, which examined patients referred between 2014 and 2025 using electronic health records from over 1,850 hospitals, is the largest and most detailed examination to date of where people fall out of the kidney transplant process.
The evaluation itself is grueling. Once referred, a patient must undergo extensive testing—blood work, chest imaging, cancer screenings—often spread across months of visits while simultaneously attending dialysis sessions every week. Only after passing all these hurdles and winning approval does a patient finally get placed on the waitlist. For someone without reliable transportation, without a spouse or partner to help coordinate appointments, or living hours away from the nearest transplant center, this gauntlet becomes nearly impossible to navigate.
The disparities are stark. Unmarried patients were significantly less likely to start or finish the evaluation. Those with severe obesity faced steeper barriers. Rural residents struggled more than their urban counterparts, partly because transplant centers cluster in cities. Older patients, Spanish-speaking patients, and those living in poverty all showed lower progression rates. Patients treated at smaller centers—which have fewer resources and fewer transplant slots—were more selective and risk-averse, the researchers found. Programs in the South showed particularly low completion rates.
Dr. Conor Donnelly, the study's lead author and a resident and PhD student at NYU Grossman School of Medicine, framed the problem plainly: "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." The complexity of the process itself is part of the problem. Smaller centers with limited staff may lack the resources to shepherd patients through multiple visits. Candidates without strong social support—no spouse, no family nearby—struggle to make repeated trips. The result is that thousands of people who could benefit from a transplant never get the chance to try.
The researchers used a massive dataset of over 300 million electronic health records to track patients through four stages: referral, evaluation, waitlist, and transplant. They analyzed how age, sex, geography, medical history, and social vulnerability—a measure of poverty, transportation access, and housing stability—affected progression at each step. The findings suggest that reducing barriers to evaluation and waitlisting could unlock access for many currently eligible patients who are falling through the cracks.
Dr. Allan Massie, a co-senior author and associate professor at NYU Langone, called for better patient education and support to help people navigate what he described as a "complex and sometimes grueling process." The team plans to extend this research to other organ transplants, where the path to the waitlist can look quite different. For now, the message is clear: the problem isn't that these patients don't need kidneys or wouldn't benefit from transplants. It's that the system itself—its geography, its complexity, its resource constraints—is filtering out people before they ever get a fair shot.
Notable Quotes
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. Conor Donnelly, study lead author, 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.— Dr. Allan Massie, co-senior author, NYU Langone Health
The Hearth Conversation Another angle on the story
Why does it matter that nearly half never start? Couldn't they just try again later?
Because kidney failure doesn't wait. These are people on dialysis, often for years, with declining health. The longer you stay on dialysis, the sicker you get. A delayed transplant is a missed transplant.
So the evaluation process itself is the barrier, not the transplant?
Exactly. The surgery is the goal, but the evaluation is the gatekeeper. It's months of appointments, tests, travel. If you're poor, unmarried, or live three hours from the nearest center, you're already exhausted before you start.
Why would smaller centers be more selective?
They have fewer slots and less staff. They can't afford to take risks on complicated cases. Larger urban centers have resources to manage more patients, so they're more likely to push people through.
Is this a new problem?
No, but nobody was really measuring it until now. Researchers have studied what happens once you're on the waitlist, but the dropout before that was invisible. This study made it visible.
What would actually fix it?
Better support—transportation help, case managers who coordinate appointments, maybe telemedicine for some tests. And simplifying the evaluation itself. Not every patient needs every test. But that requires resources and rethinking how centers operate.
How many people are we talking about?
Out of 720,000 referred patients in this study, roughly 345,000 never started evaluation. That's a lot of people who could have had a transplant but didn't get the chance.