Kidney Transplant Referrals Show Significant Attrition Before Waitlisting

Key Takeaways

• A large analysis of 720 348 patients referred for kidney transplantation between 2014 and 2025 found that only 48% initiated evaluation, 19% were waitlisted, and 10% ultimately received a kidney transplant.
• Patient characteristics, including severe obesity, rural residence, and never-married status, were associated with lower rates of evaluation initiation, while lower-volume transplant centers were associated with lower transplantation rates.
• Documentation from participating centers identified failure to meet transplant criteria, patient decisions, inability to contact patients, financial or insurance barriers, and death as common reasons patients did not progress to evaluation.

Kidney transplantation remains the preferred treatment for kidney failure because it improves survival and is more cost effective than long-term dialysis. However, new research using a large US electronic health record database found that substantial patient attrition occurs long before transplantation, highlighting persistent barriers throughout the transplant evaluation process.

Researchers analyzed Epic Cosmos electronic health record data from all patients referred for kidney transplantation between 2014 and 2025 to characterize progression through the transplant pathway and identify patient- and center-level factors associated with access to evaluation, waitlisting, and transplantation.

The study included 720 348 referred candidates. The median age was 55 years (interquartile range [IQR], 42 to 64 years), 52% were male, 47% were White, 87% primarily spoke English, and 85% resided in urban areas.

Among all referred patients, fewer than half (48%) initiated transplant evaluation. Only 19% ultimately reached the transplant waitlist, while just 10% underwent kidney transplantation.

Among patients who did begin evaluation, the median time from referral to evaluation initiation was 2 months (IQR, 1 to 4 months). For those who were eventually waitlisted, the median time from evaluation initiation to waitlisting was 4 months (IQR, 2 to 9 months).

Several patient characteristics were independently associated with lower likelihood of initiating evaluation. Patients who had never been married had an adjusted relative risk (aRR) of 0.94 (95% CI, 0.93-0.94). Patients with severe obesity were substantially less likely to begin evaluation (aRR, 0.70; 95% CI, 0.69-0.72), while patients living in rural zip codes also experienced lower rates of evaluation initiation (aRR, 0.98; 95% CI, 0.97-1.00).

Center characteristics also influenced outcomes. Low-volume transplant centers demonstrated lower transplantation rates than higher-volume centers (adjusted hazard ratio, 0.92; 95% CI, 0.88-0.96).

Among centers documenting reasons patients did not progress to evaluation, the most common were failure to meet transplant criteria or being deemed not a transplant candidate (18%), patient choice (13%), inability to contact the patient (12%), financial or insurance complications (7%), and death (4%).

The findings suggest that the greatest losses in the kidney transplant pathway occur before patients ever reach the waitlist. While referral represents an important first step, many patients encounter barriers during evaluation that prevent progression to transplantation.

The identified disparities indicate that both individual and health system factors may influence access to kidney transplantation. Socioeconomic, geographic, and insurance-related variables, along with patient characteristics such as obesity and rural residence, were associated with differences in evaluation initiation. Additionally, lower transplantation rates observed at low-volume centers suggest that institutional characteristics may also affect patient outcomes.

Documentation of reasons for non-progression further illustrates the complexity of transplant access. Clinical eligibility, patient preferences, communication challenges, and financial or insurance issues all contributed to attrition before formal evaluation was completed.

The study authors concluded that there is “substantial attrition before kidney transplant waitlisting." They further identified multiple patient- and center-level factors associated with progression through evaluation, waitlisting, and transplantation, underscoring opportunities to better understand barriers occurring early in the transplant pathway.

Overall, these findings demonstrate significant attrition across the kidney transplant process, emphasizing opportunities to improve access from referral through transplantation.

Reference

Donnelly CB, Patel SS, Husain SA, et al. Evaluating barriers to kidney transplantation in the United States. J Am Soc Nephrol. 2026. doi:10.1681/ASN.0000001162