Only 19% of referred US kidney failure patients complete transplant evaluation and reach waitlist

The Epic Cosmos analysis tracked patients from referral through evaluation, waitlisting, and transplant between 2014 and 2025 across more than 600 centers. Multivariable models showed unmarried patients, those with BMI over 35, rural residents, Spanish speakers, and individuals at smaller Southern programs progressed at markedly lower rates. Social vulnerability indices and distance to centers explained additional variance beyond clinical factors alone. These upstream barriers compound documented downstream disparities in organ allocation and post-transplant survival.

Mainstream coverage of transplant inequity has focused on waitlist mortality and organ distribution algorithms while overlooking that the majority of eligible patients never enter that pipeline. Smaller programs' risk aversion, fragmented care coordination, and absence of navigation support for patients lacking transportation or family caregivers create structural choke points. This pattern mirrors broader failures in chronic disease management where referral alone substitutes for accountable longitudinal care.

Future interventions must test standardized navigation protocols, telehealth evaluation pathways, and center-level performance metrics that include progression rates from referral, not merely waitlist volume. Without such measures, expanded organ supply will continue to benefit only the subset already advantaged enough to navigate evaluation.