Nearly Half of Patients Referred for a Kidney Transplant Fall Away

A massive study spanning more than a decade

A study led by researchers at NYU Langone Health and the NYU Grossman School of Medicine, published online on June 20, 2026 in the Journal of the American Society of Nephrology, reveals a number that should give pause to anyone concerned with access to care in the United States. Of 720,348 patients referred for a kidney transplant between 2014 and 2025, 48% never even started the medical evaluation process required before being placed on a waiting list.

Worse still, only 19% of these referred patients ultimately managed to complete this evaluation and be listed for a transplant, fewer than one in five. These figures, drawn from the Epic Cosmos database, which compiles more than 300 million electronic health records from over 1,850 institutions, paint the portrait of a system where access to transplantation remains deeply unequal.

A voice for those who wait

Behind these statistics lies the daily reality of countless dialysis patients, forced to juggle medical appointments, blood tests, and imaging exams, all while coping with fatigue and the scheduling constraints imposed by their regular dialysis sessions. This testimony gives voice to that collective experience, without claiming to recount the individual journey of any one specific person.

Months of appointments layered on top of dialysis

The evaluation required to join a kidney transplant waiting list includes repeated blood tests, chest imaging exams, cancer screenings, and multiple medical appointments that often stretch over several months. For patients already weakened by kidney failure and tied to dialysis sessions several times a week, this journey represents a considerable physical and logistical burden.

Dr. Conor B. Donnelly, the study's lead author and a research resident in the department of surgery at NYU Grossman School of Medicine, sums up the situation this way: "Our findings suggest that a substantial proportion of people who need a new kidney fall out of the process well before reaching the waiting list, let alone the operating room."

The decisive role of social support

Dr. Donnelly also highlights a factor often underestimated: "The transplant center you go to, where you live, and even whether you're married, all appear to influence your chances of moving toward the waiting list for a new kidney." This observation underscores just how much social support matters in a medical journey this long and demanding.

The American South and rural areas at a disadvantage

The study identifies several factors associated with a lower likelihood of starting or completing the evaluation: living in a rural area rather than an urban one, where access to specialized centers is harder to come by; geographic region, with a particular disadvantage for the Southern United States; and the size of the transplant center, with smaller institutions showing less favorable outcomes than large specialized centers.

Other identified factors include severe obesity, older age, lower income, and language spoken, with Spanish-speaking patients appearing particularly disadvantaged in this complex medical journey, which requires administrative navigation that can be difficult for non-English speakers.

A system that penalizes the most vulnerable

These multiple disparity factors paint the picture of a system in which already the most vulnerable patients, socially, economically, or geographically, also end up disadvantaged in their access to a treatment that is nonetheless vital. This pile-up of obstacles, rather than any single factor, appears to explain a significant share of the gap observed between initial referral and effective placement on the waiting list.

A call to reduce structural barriers

Allan B. Massie, associate professor of surgery and population health at NYU Grossman School of Medicine and senior co-author of the study, states: "These findings demonstrate that finding ways to reduce barriers to both evaluation and waitlisting could help expand access to kidney transplantation where needed." He adds that "giving patients better education and better support to help them navigate this complex and sometimes grueling process would be a good place to start."

This recommendation, coming from one of the study's lead researchers, points toward concrete, realistic solutions rather than a wholesale overhaul of the existing system, a measured stance that avoids promising any short-term miracle fix.

A converging message from the co-authors

Michal A. Mankowski, assistant professor of surgery and the study's second senior co-author, adds to this analysis: "Our findings highlight the need to better support patients as they move from referral to the waiting list, where many potentially eligible people are ultimately not listed." This shared conclusion among the entire research team reinforces the credibility of the call for targeted reform of patient support practices.

Contributors from several institutions

This study brings together a particularly large research team, including Suhani S. Patel, Syed Ali Husain, Sommer E. Gentry, Bonnie E. Lonze, Sunjae Bae, Babak J. Orandi, Mara A. McAdams-DeMarco, and Dorry L. Segev, all affiliated with NYU Grossman School of Medicine, along with Rachel Patzer of Indiana University and David Axelrod of University Hospitals Cleveland.

This collaboration across several academic institutions strengthens the study's methodological robustness, also presented at the American Transplant Congress, a leading conference in the field of organ transplantation in the United States.

Transparent funding

The study was funded by NYU Langone Health, with transparent disclosure regarding Dr. Orandi, who served on an advisory board for Boehringer Ingelheim, a relationship managed under NYU Langone's internal conflict-of-interest policies. This methodological transparency strengthens the trust one can place in the conclusions presented.

Concrete leads rather than immediate solutions

It would be dishonest to present this study as offering an immediate fix to the problem it documents. The researchers themselves stress the need for structural reforms, better administrative support, and stronger patient education, measures that will inevitably take time to roll out across the entire American health care system.

Nonetheless, the simple act of identifying disparity factors with this level of precision constitutes an essential step toward better-targeted public policies, capable of gradually narrowing the gap between the number of patients referred and the number actually placed on the transplant waiting list.

What this means for dialysis patients today

For the many patients currently on dialysis and awaiting evaluation for a kidney transplant, this study at least offers the public acknowledgment of obstacles they often live through alone and in silence, without always understanding why their own journey seems harder than that of other patients in a comparable medical situation.

Recommendations that could inform public policy

The recommendations put forward by the NYU Langone team, centered on patient education and reducing administrative barriers, could inspire concrete adjustments in how American transplant centers support their referred patients, particularly those living in rural areas or with limited resources.

These adjustments, if implemented gradually, could help narrow the considerable gap between the 48% of patients who drop out before even beginning evaluation and the 19% who actually manage to be listed, without necessarily guaranteeing a quick or complete resolution of the structural problem identified.

A necessary vigilance over the long haul

This study, however methodologically rigorous, is only a starting point for deeper work that will need to continue over several years, with regular monitoring of access indicators to kidney transplantation in order to measure the real impact of any reforms eventually implemented by health authorities and the institutions concerned.

Significant variability across institutions

The study underscores that the size and resources of a transplant center directly affect the odds that a referred patient completes evaluation. Larger centers, often better staffed with specialized personnel and stronger follow-up capacity, show significantly better outcomes than smaller institutions, which sometimes struggle to offer the same sustained support to every patient on their lists.

This variability among institutions raises a question of territorial equity: a patient referred at a large urban center statistically has better odds of reaching the waiting list than a patient followed at a more modest facility, regardless of the clinical severity of their own medical condition.

Avenues for standardization worth exploring

Faced with this finding, some researchers suggest exploring enhanced support mechanisms for smaller centers, whether through additional resources, specific training, or partnerships with more experienced institutions, in order to gradually narrow this performance gap observed nationwide.

This idea, still at a preliminary stage of consideration, illustrates the complexity of the problem identified by the study: it is not simply an issue of individual patient motivation, but truly a structural issue tied to the very organization of the American health care system as a whole.

A necessary reminder about health equity

This NYU Langone Health study is a reminder, backed by statistical rigor that is hard to dispute, that access to a life-saving treatment like kidney transplantation remains deeply unequal in the United States, shaped by geographic, social, and economic factors that have nothing to do with the medical merit of the patients involved.

A call to measured but determined action

Without giving in to naive optimism or sterile fatalism, this testimony calls for supporting the research efforts and concrete recommendations put forward by these researchers, in the measured hope that the coming years will gradually narrow the gap between the number of patients referred and the number actually treated.

By Maxime Marquette, columnist

Editorial stance

I am not a journalist but a columnist and analyst. My expertise lies in observing and analysing the geopolitical, economic and strategic dynamics that shape our world. My work is to take political strategies apart, to understand global economic movements, to put the decisions of international actors in context and to offer analytical perspectives on the changes that are redefining our societies.

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