Nearly half of Americans with kidney failure who are referred for a transplant never even start the evaluation process, according to a new nationwide study. Even more striking: fewer than one in five complete the evaluation and secure a spot on the transplant waitlist. Researchers at NYU Langone Health, who analyzed data from 720,348 patients referred between 2014 and 2025, say much attention has been given to patients once they reach the waitlist, but far less is known about why so many people never make it there. The answer, it turns out, is a depressing mix of geography, marital status, and the sheer grind of the evaluation process.

Patients who were unmarried, had severe obesity, or lived in rural communities were less likely to begin or complete a transplant evaluation. Older adults, Spanish speakers, and people with lower incomes faced even greater challenges. Patients receiving care at smaller transplant centers or programs in the Southern United States were also less likely to move forward. Overall, just 19% of referred patients completed the evaluation and were waitlisted, while 48% never started at all. As lead author Dr. Conor Donnelly put it: "Which transplant center you go to, where you live, and even whether you are married all appear to influence your chances."

The evaluation itself is a gauntlet: blood tests, chest imaging, cancer screenings, and multiple appointments over several months - all while the patient is still attending regular dialysis treatments. Smaller transplant centers may have fewer resources and be more selective, and patients without social support struggle with transportation and logistics. Urbanites, who tend to live closer to transplant centers, fared better. The study, published June 20 in the Journal of the American Society of Nephrology and presented at the American Transplant Congress, is the largest to date tracking the kidney transplant dropout rate. Researchers used Epic Cosmos, a database of over 300 million electronic health records from more than 1,850 hospitals, including over a third of U.S. transplant centers.

Co-senior author Dr. Allan B. Massie suggested the fix: "Providing patients with better education and support to help them navigate the complex and sometimes grueling process would be a good start." Co-senior author Dr. Michal A. Mankowski added that future research will apply the same approach to other organ transplants, because why limit the despair to kidneys?