Major Barriers Before Kidney Transplant Waiting Lists

A new study suggests that many people with kidney failure face serious difficulties long before a suitable organ donor becomes available. For many patients, the greatest challenge is completing the complex kidney transplant process and reaching the official waiting list.

Researchers found that nearly half of American kidney patients referred for a kidney transplant never begin the required medical evaluation process. Fewer than one in five complete all the necessary assessments and receive a place on the national transplant waitlist.

These findings reveal an important gap in transplant care. Previous research has mainly focused on patients who have already joined the waiting list, while less attention has been given to those who are delayed or lost during the earlier referral and assessment stages.

Understanding these barriers may help healthcare providers improve patient access, reduce delays, and ensure that more eligible people can move successfully through the transplant system.

Unequal Access to Kidney Transplant Assessment

Researchers from NYU Langone Health examined records from 720,348 patients referred for a kidney transplant. Their findings revealed major differences in who successfully moved through the transplant pathway.

Patients who were unmarried, severely obese, or living in rural areas were less likely to begin or finish the required transplant evaluation. Even greater barriers affected older adults, people with lower incomes, and patients who mainly spoke Spanish.

Access also depended on where patients received care. Those referred to smaller transplant centres or programmes in the southern United States were less likely to reach the national kidney transplant waitlist.

Overall, only 19 per cent of referred patients completed the evaluation and joined the waitlist. In contrast, 48 per cent never started the assessment process.

Lead researcher Dr Conor Donnelly explained that many patients leave the system long before they have a chance to receive a donor kidney. Factors such as location, marital status, healthcare resources, and the transplant centre involved may all affect a patient’s chances of moving forward.

Why Transplant Assessments Are Hard to Complete

The kidney transplant evaluation process is detailed and often takes several months. After being referred, patients must undergo a wide range of health checks to confirm whether transplantation is safe and suitable for them.

These assessments may include blood tests, chest scans, cancer screening, heart checks, and other medical examinations. Patients may need to attend several appointments while also continuing regular dialysis treatment.

Only after completing every requirement and receiving approval can a patient be added to the transplant waitlist.

Smaller centres may have limited staff, funding, and transplant opportunities, which could make them more selective when accepting candidates. Patients without strong social support may also struggle to arrange transport, manage repeated appointments, or take time away from work and family responsibilities.

The findings suggest that improving transport, communication, financial support, and access to larger transplant programmes could help more patients complete the process and receive fair consideration for a kidney transplant.

Where Patients Leave the Transplant Pathway

Patients living in urban areas were generally more likely to continue through the kidney transplant process. One possible reason is that transplant centres, specialist services, and transport options are often easier to access in cities than in rural communities.

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Nationwide Analysis of Transplant Progress

The study, published online on 20 June in the Journal of the American Society of Nephrology, is described by the researchers as the largest and most detailed investigation of where patients leave the transplant pathway before joining the waiting list.

The findings were also presented at the American Transplant Congress, organised jointly by the American Society of Transplantation and the American Society of Transplant Surgeons.

Researchers used Epic Cosmos, a large database containing more than 300 million electronic health records from over 1,850 hospitals. The records included information from more than one-third of transplant centres in the United States.

The team studied adults referred for a kidney transplant between 2014 and 2025. Each patient was followed through four main stages: referral, medical evaluation, waitlisting, and transplantation.

Social Conditions Affect Access to Care

Using statistical modelling, researchers examined how age, sex, health history, and geographic location affected a patient’s chance of moving through each stage.

They also considered social vulnerability, which includes difficulties linked to poverty, unstable housing, poor transport, and limited access to healthcare. These conditions can make it harder for patients to attend appointments, complete medical tests, and understand complex transplant requirements.

Study co-senior author Allan B. Massie explained that reducing barriers during evaluation and waitlisting could improve access to kidney transplantation. He suggested that clearer patient education, practical guidance, and stronger support systems could help more people complete the demanding transplant process.

Improving Support Before Transplant Waitlisting

The findings show that many potentially eligible patients need stronger support to move from kidney transplant referral to the official waiting list. Study co-senior author Michal A. Mankowski, PhD, explained that a large number of patients may qualify for transplantation but are never successfully listed.

Mankowski, an assistant professor in the Department of Surgery at NYU Grossman School of Medicine, said future studies will use a similar method to examine other forms of organ transplantation. The assessment and waitlisting process can vary greatly depending on the organ involved.

Researchers and Partner Institutions

The study involved a large team of specialists from NYU Langone Health, including researchers with expertise in surgery, public health, transplant medicine, epidemiology, and population health. External collaborators also included Rachel Patzer of Indiana University and David Axelrod of University Hospitals in Cleveland.

Their combined work helped examine how medical, social, and healthcare-system factors influence access to transplant evaluation, waitlisting, and organ transplantation.

Funding and Disclosure Information

The researchers also reported potential professional relationships to maintain research transparency. Dr Babak J. Orandi previously served on an advisory board for the pharmaceutical company Boehringer Ingelheim. NYU Langone Health stated that this relationship is managed according to its institutional policies and procedures.

The research was funded by NYU Langone Health.

Summary: Nearly Half of Kidney Patients Never Start [Shocking]

Nearly half of US patients referred for a kidney transplant never begin the required evaluation, while only 19 per cent reach the waiting list.Older adults, rural residents, Spanish speakers, lower-income patients, and those without strong social support face greater barriers.Complex testing, repeated appointments, transport problems, and limited resources at smaller transplant centres can delay progress.The study shows that social, geographic, and healthcare-system factors strongly influence access to transplantation.Researchers recommend better education, transport assistance, communication, and patient support to help more eligible people reach the waitlist.