{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T03:05:29Z","timestamp":1793156729328,"version":"4.5.0"},"reference-count":32,"publisher":"Ovid Technologies (Wolters Kluwer Health)","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["JASN"],"abstract":"\n Key Points<\/jats:title>\n \n \n \n In this cohort study of 720,348 adults referred for kidney transplantation from 2014 to 2025, only 48% were evaluated and 19% were waitlisted.<\/jats:p>\n <\/jats:list-item>\n \n Progression from referral to evaluation, waitlisting, and kidney transplantation was limited by individual, center-level, and geographic factors.<\/jats:p>\n <\/jats:list-item>\n \n Some centers evaluated and waitlisted patients at rates far below the national average, and low-volume centers had lower rates of transplantation.<\/jats:p>\n <\/jats:list-item>\n <\/jats:list>\n <\/jats:p>\n <\/jats:sec>\n \n Background<\/jats:title>\n Kidney transplantation is a cost-effective, lifesaving treatment of kidney failure, compared with dialysis. Unfortunately, most patients with kidney failure never undergo transplantation.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Using Epic Cosmos electronic health record data on all patients referred for kidney transplantation from 2014 to 2025, we assessed the stage-specific progression and attrition in the process of evaluation, waitlisting, and kidney transplantation. Center-level and individual (socioeconomic, geographic, and insurance status) factors associated with access to evaluation, waitlisting, and kidney transplantation were characterized using modified Poisson regression.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Among 720,348 referred candidates, the median age was 55 years (interquartile range [IQR], 42\u201364); 47% of patients were White, 52% were male, and 87% were English speaking. Eighty-five percent of patients lived in urban areas. Of the referred candidates, 48% initiated evaluation, 19% were waitlisted, and 10% ultimately underwent transplantation. Among the referred patients who initiated evaluation, the median (IQR) time to evaluation initiation was 2 (1\u20134) months after referral; among the patients who were waitlisted, the median (IQR) time to waitlisting was 4 (2\u20139) months after evaluation initiation. Patients who were never married (adjusted relative risk, 0.94; 95% confidence interval [CI], 0.93 to 0.94), had severe obesity (0.70; 95% CI, 0.69 to 0.72), or were from rural zip codes (0.98; 95% CI, 0.97 to 1.00) were less likely to initiate evaluation. Low-volume centers had lower relative rates of transplantation (adjusted hazard ratio, 0.92; 95% CI, 0.88 to 0.96). In centers with documentation for nonprogression to evaluation, reasons for removal included not meeting criteria\/not a candidate (18%), patient decision (13%), unable to contact (12%), death (4%), and financial\/insurance complications (7%).<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Our study shows substantial attrition before kidney transplant waitlisting.<\/jats:p>\n <\/jats:sec>","DOI":"10.1681\/asn.0000001162","type":"journal-article","created":{"date-parts":[[2026,6,20]],"date-time":"2026-06-20T21:00:07Z","timestamp":1781989207000},"update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":1,"title":["Evaluating Barriers to Kidney Transplantation in the United States"],"prefix":"10.1681","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-0826-8107","authenticated-orcid":false,"given":"Conor B.","family":"Donnelly","sequence":"first","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-5925-9925","authenticated-orcid":false,"given":"Suhani S.","family":"Patel","sequence":"additional","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1823-0117","authenticated-orcid":false,"given":"Syed Ali","family":"Husain","sequence":"additional","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4530-8917","authenticated-orcid":false,"given":"Sommer E.","family":"Gentry","sequence":"additional","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"},{"name":"Department of Population Health, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2573-9963","authenticated-orcid":false,"given":"Rachel E.","family":"Patzer","sequence":"additional","affiliation":[{"name":"Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana"},{"name":"Center for Health Services Research, Regenstrief Institute, Indianapolis, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0973-1657","authenticated-orcid":false,"given":"Bonnie E.","family":"Lonze","sequence":"additional","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0098-8816","authenticated-orcid":false,"given":"Sunjae","family":"Bae","sequence":"additional","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5684-0613","authenticated-orcid":false,"given":"David","family":"Axelrod","sequence":"additional","affiliation":[{"name":"Department of Surgery, University Hospitals System, Cleveland, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6026-7135","authenticated-orcid":false,"given":"Babak J.","family":"Orandi","sequence":"additional","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3013-925X","authenticated-orcid":false,"given":"Mara A.","family":"McAdams-DeMarco","sequence":"additional","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"},{"name":"Department of Population Health, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1924-4801","authenticated-orcid":false,"given":"Dorry L.","family":"Segev","sequence":"additional","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"},{"name":"Department of Population Health, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5288-5125","authenticated-orcid":false,"given":"Allan B.","family":"Massie","sequence":"additional","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"},{"name":"Department of Population Health, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9923-7408","authenticated-orcid":false,"given":"Michal A.","family":"Mankowski","sequence":"additional","affiliation":[{"name":"Department of Surgery, NYU Grossman School of Medicine, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2026,6,20]]},"reference":[{"issue":"10","key":"B1-20260717","doi-asserted-by":"crossref","first-page":"2093","DOI":"10.1111\/j.1600-6143.2011.03686.x","article-title":"Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes: systematic review of kidney transplantation","volume":"11","author":"Tonelli","year":"2011","journal-title":"Am J Transplant."},{"issue":"11","key":"B3-20260717","doi-asserted-by":"crossref","first-page":"1238","DOI":"10.1001\/jamainternmed.2023.5013","article-title":"Disparities in kidney transplant waitlisting among young patients without medical comorbidities","volume":"183","author":"Husain","year":"2023","journal-title":"JAMA Intern 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evaluation","volume":"99","author":"Dageforde","year":"2015","journal-title":"Transplantation."},{"issue":"5","key":"B11-20260717","doi-asserted-by":"crossref","first-page":"799","DOI":"10.1016\/j.xkme.2021.04.017","article-title":"Improving access to kidney transplantation: perspectives from dialysis and transplant staff in the Southeastern United States","volume":"3","author":"Browne","year":"2021","journal-title":"Kidney Med."},{"issue":"4","key":"B12-20260717","doi-asserted-by":"crossref","first-page":"100654","DOI":"10.1016\/j.trre.2021.100654","article-title":"Non-medical barriers in access to early steps of kidney transplantation in the United States - a scoping review","volume":"35","author":"Harding","year":"2021","journal-title":"Transplant Rev (Orlando)."},{"issue":"8","key":"B13-20260717","doi-asserted-by":"crossref","first-page":"2113","DOI":"10.1111\/ajt.15791","article-title":"Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States","volume":"20","author":"Patzer","year":"2020","journal-title":"Am J Transplant."},{"issue":"1","key":"B14-20260717","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1007\/s10880-023-09953-5","article-title":"Predicting kidney transplant evaluation non-attendance","volume":"31","author":"Ford","year":"2024","journal-title":"J Clin Psychol Med Settings."},{"issue":"7","key":"B15-20260717","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1097\/TP.0b013e3182637078","article-title":"Clinical practice guidelines on wait-listing for kidney transplantation: consistent and equitable?: consistent and equitable?","volume":"94","author":"Batabyal","year":"2012","journal-title":"Transplantation."},{"issue":"7","key":"B16-20260717","doi-asserted-by":"crossref","first-page":"e13837","DOI":"10.1111\/petr.13837","article-title":"Genetic disease and intellectual disability as contraindications to transplant listing in the United States: a survey of heart, kidney, liver, and lung transplant programs","volume":"24","author":"Wall","year":"2020","journal-title":"Pediatr Transplant."},{"issue":"6","key":"B17-20260717","doi-asserted-by":"crossref","first-page":"843","DOI":"10.2215\/CJN.12541019","article-title":"Association of socioeconomic status and comorbidities with racial disparities during kidney transplant evaluation","volume":"15","author":"Murphy","year":"2020","journal-title":"Clin J Am Soc Nephrol."},{"issue":"7","key":"B18-20260717","doi-asserted-by":"crossref","first-page":"618","DOI":"10.1001\/jamasurg.2019.0512","article-title":"Association of racial disparities with access to kidney transplant after the implementation of the new kidney allocation system","volume":"154","author":"Kulkarni","year":"2019","journal-title":"JAMA Surg."},{"issue":"12","key":"B19-20260717","doi-asserted-by":"crossref","first-page":"1120","DOI":"10.1001\/jamasurg.2021.4410","article-title":"Evaluation of community-level 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providers","volume":"6","author":"Crenesse-Cozien","year":"2019","journal-title":"J Racial Ethn Health Disparities."},{"issue":"12","key":"B30-20260717","doi-asserted-by":"crossref","first-page":"2276","DOI":"10.2215\/CJN.04940610","article-title":"The interplay of socioeconomic status, distance to center, and interdonor service area travel on kidney transplant access and outcomes","volume":"5","author":"Axelrod","year":"2010","journal-title":"Clin J Am Soc Nephrol."},{"issue":"11","key":"B31-20260717","doi-asserted-by":"crossref","first-page":"2402","DOI":"10.1111\/j.1600-6143.2008.02413.x","article-title":"Neighborhood poverty and kidney transplantation among US Asians and Pacific Islanders with end-stage renal disease","volume":"8","author":"Hall","year":"2008","journal-title":"Am J Transplant."},{"issue":"5","key":"B32-20260717","doi-asserted-by":"crossref","first-page":"684","DOI":"10.1053\/j.ajkd.2023.12.009","article-title":"Access to the transplant waiting list: 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transplantation in the United States","volume":"97","author":"Davis","year":"2014","journal-title":"Transplantation."},{"issue":"4","key":"B36-20260717","doi-asserted-by":"crossref","first-page":"827","DOI":"10.1681\/ASN.2013070684","article-title":"Geographic determinants of access to pediatric deceased donor kidney transplantation","volume":"25","author":"Reese","year":"2014","journal-title":"J Am Soc Nephrol."},{"issue":"11","key":"B37-20260717","doi-asserted-by":"crossref","first-page":"2474","DOI":"10.1016\/j.ekir.2023.08.002","article-title":"Geographic differences in racial disparities in access to kidney transplantation","volume":"8","author":"McPherson","year":"2023","journal-title":"Kidney Int Rep."},{"issue":"2S1","key":"B38-20260717","doi-asserted-by":"crossref","first-page":"S22","DOI":"10.1016\/j.ajt.2025.01.020","article-title":"OPTN\/SRTR 2023 annual data report: Kidney","volume":"25","author":"Lentine","year":"2025","journal-title":"Am J 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