We aimed to describe nephrologists' attitudes to patients' access to kidney transplantation. Studies that assessed nephrologists' perspectives toward patient referral, screening, and eligibility for kidney transplantation were synthesized. Twenty-four studies (n≥4695) were included. Patients with comorbidities, were nonadherent, of older age, ethnic minorities, or low socioeconomic status were less likely to be recommended. Six themes underpinned nephrologists' perspectives: prioritizing individual benefit and safety, maximizing efficiency, patient accountability, justifying gains, protecting unit outcomes, and reluctance to raise patients' expectations. Evidence-based guidelines may support systematic and equitable decision-making. Interventions for high-risk or disadvantaged patient populations could reduce disparities in access to transplantation.