Michal A. Mankowski, PhD, is a research assistant professor at the Department of Surgery at NYU Langone.

Michal A. Mankowski, PhD

Why Fewer Than Half of Referred Patients Reach Kidney Transplant Waitlist

A recent study conducted by NYU Langone investigators revealed that nearly half of patients seeking a 

never initiate evaluation, according to data from > 1/3 of all US transplant centers.

By leveraging Epic Cosmos, a dataset of more than 300 million electronic health records from 1850 hospitals, investigators identified that of 720,348 patients referred for kidney transplantation, 48% initiated evaluation, 19% were waitlisted, and 10% ultimately underwent transplantation.

Conor Donnelly, MD, is a surgical resident at NYU Langone.

Allan B. Massie, PhD, is an associate professor in the Department of Surgery and an associate professor in the Department of Population Health at NYU Langone.

"What our study finds is that the [transplant] center you go to, the characteristics about where you live and who you are impact whether or not you progress towards transplantation," lead author, Donnelly, told HCPLive in an interview. "A lot of the prior studies have looked at patients who have been already waitlisted and found that it's difficult to actually get transplanted, but our study looks at prior steps in this process and finds that it's very difficult for patients to get on the wait list."

Traditionally, studies have measured waitlist and transplant outcomes, but have not primarily tracked patients at the moment of waitlisting. Massie referred to the lack of national data on patient characteristics or outcomes prior to waitlisting as a "black box."

For the first time, investigators had access to national data that could provide insight into the process of the 4 stages of kidney transplants: referral, evaluation, waitlist, and transplant.

Using statistical models, they analyzed the impact of a wide range of factors, from age and sex to geographic location and medical history, on the progressive steps in the process.

Additionally, investigators 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.

If Patients Need a Kidney Transplant, Why Aren't They Getting One?

Donnelly, Massie, Mankowski, and colleagues identified several patient characteristics that were associated with reduced rates of evaluation initiation. These include individuals who were never married (Relative Risk [RR] 0.94; 95% Confidence Interval [CI], 0.93 to 0.94), patients with severe obesity (RR, 0.70; 95% CI, 0.69 to 0.72), and those residing in rural zip codes (RR, 0.98; 95% CI, 0.97 to 1.00).

Furthemore, patients who identified as older, of reduced socioeconomic status, and those who spoke Spanish as their first language were especially unlikely to progress. Patients treated at small centers or at programs in the South were similarly unlikely to progress.

In centers with documentation for nonprogression to evaluation, 18% of reasons for removal included not meeting criteria/not a candidate, 13% were patient decisions, 12% were unable to contact, 4% were death, and 7% were financial/insurance complications.

How Can Nephrologists Help Patients Get Waitlisted For Kidney Transplants?

"When we're finding that less than half of patients are even evaluated, then nephrologists need to recognize that that referral isn't the end of the line," Massie said in an interview with HCPLive. "They can follow up with patients, they can see if patients are having practical barriers, if they're unable to get in contact with the transplant center, if they have logistical barriers to making an appointment happen."

Once a referral occurs, Massie and colleagues encourage nephrologists to take the extra step of following up with patients and transplant centers to monitor patient outcomes.

Editor’s Note: Connelly, Mankowski, and Massie report no relevant disclosures. 

Donnelly, C. B., Patel, S. S., Husain, S. A., Gentry, S. E., Patzer, R. E., Lonze, B. E., Bae, S., Axelrod, D., Orandi, B. J., McAdams-DeMarco, M. A., Segev, D. L., Massie, A. B., & Mankowski, M. A. (2026). Evaluating Barriers to Kidney Transplantation in the United States. Journal of the American Society of Nephrology. 

Most People Seeking a Kidney Transplant Never Reach the Waitlist. (2026). NYU Langone News. 

https://nyulangone.org/news/most-people-seeking-kidney-transplant-never-reach-waitlist

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Nearly half of kidney transplant candidates never start evaluation with access barriers varying by patient background.



Michal A. Mankowski, PhD

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