Can Transplant Center Referral Impact Kidney Transplant Evaluation?

A referral for kidney transplantation is only the beginning of a nephrologist's journey with their patient. A recent study from NYU Langone identified that among more than 720,000 patients referred for kidney transplantation, nearly half never initiated evaluation. One of the strongest predictors of whether patients progressed? The transplant center to which they were referred.

"We've learned that not all transplant centers are created equal, and in fact, the transplant center is one of the most important variables determining whether or not a patient actually makes it," Allan B. Massie, PhD, an associate professor in the Departments of Surgery and Population Health at NYU Langone, told HCPLive in part 2 of an interview.

For nephrologists, particularly those practicing in metropolitan areas with multiple transplant programs, Massie said referral destination should be viewed as an important clinical decision. Investigators identified substantial variation in how quickly transplant centers move patients through evaluation, suggesting differences in center workflows, available resources, and patient support may influence whether referred patients ultimately reach the waitlist.

"You should be informed to which transplant center you're referring to, because that really makes a difference," Michal A. Mankowski, PhD, is a research assistant professor at the Department of Surgery at NYU Langone said.

Check Out Part 1: Why Fewer Than Half of Referred Patients Reach Kidney Transplant Evaluation

Leveraging Epic Cosmos EHR Data to Understand Kidney Transplant Attrition

Massie, Conor Donnelly, MD, Michal Mankowski, PhD, and colleagues analyzed Epic Cosmos, a database containing more than 300 million electronic health records from 1850 hospitals, making it the largest and most detailed cohort study to date examining where patients fall out of the kidney transplant process.

Among 720,348 referred candidates, the median age was 55 years (interquartile range [IQR], 42-64), 47% were White, 52% were male, 87% were English speaking, and 85% lived in urban areas.

The findings demonstrated substantial attrition across the kidney transplant pathway.

Among patients who initiated evaluation, the median (IQR) time from referral to evaluation initiation was two (1-4) months. Among patients who were waitlisted, the median (IQR) time from evaluation initiation to waitlisting was four (2-9) months.

For centers documenting reasons patients did not progress to evaluation, the most common reasons included not meeting transplant criteria or not being a candidate (18%), patient decision (13%), inability to contact the patient (12%), financial or insurance complications (7%), and death (4%).

Beyond transplant center variation, investigators also identified several patient characteristics associated with a lower likelihood of initiating transplant evaluation. Patients who were never married (relative risk [RR], 0.94; 95% confidence interval [CI], 0.93-0.94), had severe obesity (RR, 0.70; 95% CI, 0.69-0.72), or lived in rural ZIP codes (RR, 0.98; 95% CI, 0.97-1.00) were less likely to begin evaluation. Investigators also observed reduced relative rates of transplantation among low-volume transplant centers (RR, 0.92; 95% CI, 0.88-0.96).

Why Are Patients Falling Through the Cracks?

According to Donnelly, the findings help identify patients most likely to fall out of the transplant process before they even begin evaluation.

"Our study identifies subpopulations of patients that are very likely to fall through the system," Donnelly told HCPLive. "When you have a patient that you're referring to a transplant center that doesn't have private insurance, that is obese, that has comorbidities, these are patients that are very likely to fall through the system, and I think that they probably need support."

The transplant evaluation process itself can present significant barriers. Patients often undergo months of testing, imaging, cancer screenings, and repeated clinic visits while continuing dialysis treatment, creating numerous opportunities for patients to disengage before reaching the waitlist. Donnelly suggested earlier support, including assistance navigating financial, transportation, and logistical barriers, may help more patients successfully complete evaluation.

Small Barriers Can Become Large Disparities

While the study identified several patient- and center-level factors associated with lower progression through the transplant pathway, Massie said one of its most important findings was how those barriers accumulate over time.

"The most interesting thing that I learned is that all of these steps have to be overcome in order to get listed. It's really a cumulative process," Massie said. "If you look at patients that are ethnic minorities or socioeconomically disadvantaged or have other problems, at each stage there might be a very slight difference in risk of progression, but when you add it all up, it adds to an enormous difference."

Rather than focusing only on patients who reach the waitlist, these investigators said the findings emphasize the importance of examining the earliest stages of the transplant pathway, where the greatest attrition occurs.

"If we want to create an equitable system for patients, we need to look at these early steps as well," Massie said. "Patients are being lost here."

Although not every referred patient will ultimately qualify for transplantation, investigators emphasized that patients cannot be determined ineligible until they complete the evaluation process. Improving access to evaluation through earlier patient support and informed referral decisions may help more eligible patients ultimately reach the waitlist and receive a transplant.

“We strongly believe that way more people could have been waitlisted, and again, we see huge attrition just from being referred to start of evaluation,” concluded Manowski.

Editor's Note: Donnelly, Mankowski, and Massie report no relevant disclosures.

References

1. 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. https://doi.org/10.1681/asn.0000001162

2. Most People Seeking a Kidney Transplant Never Reach the Waitlist. NYU Langone News. Published 2026. Accessed July 15, 2026. https://nyulangone.org/news/most-people-seeking-kidney-transplant-never-reach-waitlist