The High Cost of the Waitlist Pipeline
Nearly half of Americans with kidney failure who are referred for a kidney transplant never start the mandatory evaluation. Even more sobering: fewer than one in five ultimately secure a spot on the transplant waitlist. A study published in the Journal of the American Society of Nephrology confirms that geography, socioeconomic status, and social support systems dictate who advances through the pipeline.
The Rigors of the Evaluation Phase
The journey from referral to the waitlist is a multi-stage process. Researchers from NYU Langone Health analyzed data from 720,348 patients and found a stark reality: 48% of those referred never initiate the evaluation phase.
For those who do start, the burden is immense. Patients must complete comprehensive medical assessments—including cancer screenings, chest imaging, and blood panels—all while tethered to a regular dialysis schedule. The logistical weight of these appointments, spread across several months, often proves insurmountable.
Demographic and Geographic Hurdles
Success in the transplant process is rarely random. The study identified severe obesity, rural residency, and unmarried status as primary predictors of being less likely to begin or complete a transplant evaluation and reach the waitlist.
"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 Conor Donnelly, MD, a resident and PhD student at NYU Grossman School of Medicine.
Geography acts as a filter. Patients at smaller transplant centers or those living in the Southern United States are less likely to reach the waitlist than those treated in urban centers where transplant centers are often more accessible.
A Data-Driven Analysis of Failure
Published on June 20, this research stands as the largest and most detailed study to date examining where patients leave the kidney transplant pathway before reaching the waitlist. The team utilized the Epic Cosmos database to aggregate electronic health records from more than 1,850 hospitals.
By tracking adult patients referred between 2014 and 2025, researchers mapped four distinct stages: referral, evaluation, waitlist, and transplant. Through statistical modeling, the team accounted for variables like social vulnerability, unstable housing, and transportation limitations—factors that often prevent patients from successfully engaging with the healthcare system.
Targeting Support for Vulnerable Patients
Systemic change is required to bridge these gaps. Co-senior author Allan B. Massie, PhD, an associate professor in the Departments of Surgery and Population Health at NYU Grossman School of Medicine, emphasized that improving patient education and providing direct support during the evaluation process are necessary first steps.
The researchers, including co-senior author Michal A. Mankowski, PhD, an assistant professor in the Department of Surgery at NYU Grossman School of Medicine, now intend to apply this methodology to other organ transplantation pathways. By identifying exactly where patients drop out of the system, hospitals may be better equipped to provide targeted interventions for those at the highest risk of being excluded from life-saving care.