Trends in the inactive kidney transplant waitlist and implications for candidate survival

In November 2003, OPTN policy was amended to allow kidney transplant candidates to accrue waiting time while registered as status 7, or inactive. We evaluated trends in inactive listings and the association of inactive status with transplantation and survival, studying 262,824 adult first-time KT candidates listed between 2000 and 2011. The proportion of waitlist candidates initially listed as inactive increased from 2.3% prepolicy change to 31.4% in 2011. Candidates initially listed as inactive were older, more often female, African American, and with higher body mass index. Postpolicy change, conversion from initially inactive to active status generally occurred early if at all: at 1 year after listing, 52.7% of initially inactive candidates had been activated; at 3 years, only 66.3% had been activated. Inactive status was associated with a substantially higher waitlist mortality (aHR 2.21, 95%CI:2.15-2.28, p<0.001) and lower rates of eventual transplantation (aRR 0.68, 95%CI:0.67-0.70, p<0.001). In summary, waitlist practice has changed significantly since November 2003, with a sharp increase in the number of inactive candidates. Using the full waitlist to estimate organ shortage or as a comparison group in transplant outcome studies is less appropriate in the current era.