Nearly half of patients referred for kidney transplantation never begin the evaluation process, according to a large study that reveals significant gaps in how candidates progress toward life-saving surgery. Researchers analyzed data from over 720,000 patients referred for kidney transplants between 2014 and 2025, uncovering a troubling pattern of attrition at every stage of the transplant journey.

What Percentage of Kidney Transplant Candidates Actually Complete the Process?

The numbers paint a stark picture of how many patients fall out of the transplant pipeline. Of all patients referred for kidney transplantation, only 48 percent initiated evaluation, 19 percent were waitlisted, and just 10 percent ultimately underwent transplantation. For those who did begin evaluation, the median time to start the process was two months after referral. Once evaluation began, the median time to waitlisting was four months.

"Our findings suggest that a substantial proportion of people who need a new kidney fall out of the process long before they reach the waitlist, let alone make it to the operating room," said Dr. Conor B. Donnelly, from NYU Grossman School of Medicine.

Dr. Conor B. Donnelly, NYU Grossman School of Medicine

Who Is Most Likely to Drop Out of Kidney Transplant Evaluation?

The research identified specific groups facing higher barriers to entering the transplant evaluation process. Patients who had never been married were less likely to initiate evaluation, as were those with severe obesity. Geographic location also mattered significantly; patients from rural ZIP codes had lower rates of starting the evaluation process compared to their urban counterparts.

Beyond individual characteristics, the transplant center itself influenced outcomes. Patients evaluated at low-volume transplant centers experienced lower rates of ultimately receiving a transplant, suggesting that center experience and resources play a meaningful role in patient success.

What Are the Main Reasons Patients Don't Progress in the Transplant Process?

Among centers that documented why patients failed to advance to evaluation, several barriers emerged:

• Medical Disqualification: Eighteen percent of patients were deemed not to meet criteria or were determined not to be suitable candidates for transplantation.
• Patient Choice: Thirteen percent of referred patients decided not to pursue transplant evaluation on their own.
• Contact Challenges: Twelve percent of patients could not be reached or contacted by transplant centers to begin the process.
• Financial and Insurance Barriers: Seven percent of patients faced complications related to financial resources or insurance coverage that prevented them from moving forward.
• Death: Four percent of referred patients died before they could initiate evaluation.

These barriers reveal that the obstacles to kidney transplantation extend far beyond medical considerations. Financial constraints, geographic isolation, and communication gaps all play significant roles in whether patients can access this life-changing treatment.

How to Improve Your Chances of Completing Kidney Transplant Evaluation

While individual patients cannot control all factors influencing transplant access, understanding the process and potential barriers can help:

• Stay Connected: Maintain regular contact with your transplant center and respond promptly to communications. The data shows that patients who cannot be reached face significant delays or removal from the process.
• Understand Your Financial Options: Explore insurance coverage, financial assistance programs, and payment plans early. Financial complications account for a meaningful portion of patient attrition, so addressing these concerns upfront can prevent later barriers.
• Seek Centers with Strong Track Records: If possible, work with transplant centers that perform higher volumes of transplants, as these centers demonstrate better outcomes for moving patients through evaluation to actual transplantation.
• Ask Questions About Candidacy: If you are referred for transplant evaluation, ask your nephrologist or transplant team to clearly explain any medical concerns that might affect your candidacy, so you understand what to expect.

The study, published in June 2026 in the Journal of the American Society of Nephrology to coincide with the annual American Transplant Congress, represents one of the most comprehensive analyses of transplant candidate attrition to date. By identifying where and why patients drop out of the process, researchers hope to inform strategies that help more kidney disease patients access transplantation, which offers superior long-term outcomes compared to remaining on dialysis.

For patients with chronic kidney disease (CKD) or end-stage renal disease, kidney transplantation represents a pathway to better quality of life and longer survival. However, this research underscores that simply being referred for transplant is not enough. Healthcare systems and transplant centers must work to address the financial, geographic, and logistical barriers that prevent nearly half of referred patients from even beginning the evaluation journey.