The kidney transplant waiting list
- Gabriel Danovitch, MD
Gabriel Danovitch, MD
- Professor of Medicine
- University of California, Los Angeles
As of late 2010, a total of approximately 93,000 patients were registered on the kidney transplant waiting list at the United Network for Organ Sharing (UNOS) in the United States [1,2]. Registration on this list by individual transplant programs is required before a patient can be allocated a deceased donor organ. Over 30 percent of the list is registered in an "inactive" status, the significance of which will be discussed below.
This topic review will discuss the composition of and access to the kidney transplant waitlist, as well as the management of patients while they await allocation of a kidney. Additional information is available elsewhere [1,3-5] and on the UNOS website (www.UNOS.org).
The details of the allocation algorithm for deceased donor kidneys and issues related to the evaluation of the kidney transplant candidate, including the possible presence of coronary disease, are discussed separately. (See "Evaluation of the potential renal transplant recipient" and "Organ sharing in kidney transplantation".)
THE ACTIVE AND INACTIVE LIST
The kidney transplant waiting list in the United States had been expanding by 3000 to 4000 patients each year . However, the steady increase in the number of so-called active candidates has slowed, and, since 2001, this number has been stable at approximately 50,000 .
Current policy permits inactive candidates (also called "status 7") to accrue waiting time points; however, only active patients are allocated transplants. The purpose of this policy is to encourage transparency in listing so that the active transplant list truly reflects candidates who are prepared for imminent transplantation. Candidates are placed in an inactive status if an intercurrent condition develops that makes transplantation temporarily inadvisable (eg, during a hiatus after a treated malignancy while on the waiting list), although it is likely that some patients remain on the list despite conditions that are not reversible or while their initial work-up is being completed.
- Leichtman AB, Cohen D, Keith D, et al. Kidney and pancreas transplantation in the United States, 1997-2006: the HRSA Breakthrough Collaboratives and the 58 DSA Challenge. Am J Transplant 2008; 8:946.
- Axelrod DA, McCullough KP, Brewer ED, et al. Kidney and pancreas transplantation in the United States, 1999-2008: the changing face of living donation. Am J Transplant 2010; 10:987.
- Cohen DJ, St Martin L, Christensen LL, et al. Kidney and pancreas transplantation in the United States, 1995-2004. Am J Transplant 2006; 6:1153.
- Gaston RS, Danovitch GM, Adams PL, et al. The report of a national conference on the wait list for kidney transplantation. Am J Transplant 2003; 3:775.
- Danovitch GM, Cohen DJ, Weir MR, et al. Current status of kidney and pancreas transplantation in the United States, 1994-2003. Am J Transplant 2005; 5:904.
- Huang E, Poommipanit N, Sampaio MS, et al. Intermediate-term outcomes associated with kidney transplantation in recipients 80 years and older: an analysis of the OPTN/UNOS database. Transplantation 2010; 90:974.
- Schaeffner ES, Rose C, Gill JS. Access to kidney transplantation among the elderly in the United States: a glass half full, not half empty. Clin J Am Soc Nephrol 2010; 5:2109.
- Bunnapradist S, Danovitch GM. Kidney transplants for the elderly: hope or hype? Clin J Am Soc Nephrol 2010; 5:1910.
- Schold J, Srinivas TR, Sehgal AR, Meier-Kriesche HU. Half of kidney transplant candidates who are older than 60 years now placed on the waiting list will die before receiving a deceased-donor transplant. Clin J Am Soc Nephrol 2009; 4:1239.
- Schold JD, Srinivas TR, Kayler LK, Meier-Kriesche HU. The overlapping risk profile between dialysis patients listed and not listed for renal transplantation. Am J Transplant 2008; 8:58.
- Dudley CR, Johnson RJ, Thomas HL, et al. Factors that influence access to the national renal transplant waiting list. Transplantation 2009; 88:96.
- Schold JD, Meier-Kriesche HU. Comparable barriers to access to kidney transplantation across national lines. Transplantation 2009; 88:21.
- Meier-Kriesche HU, Ojo AO, Port FK, et al. Survival improvement among patients with end-stage renal disease: trends over time for transplant recipients and wait-listed patients. J Am Soc Nephrol 2001; 12:1293.
- Gill JS, Rose C, Pereira BJ, Tonelli M. The importance of transitions between dialysis and transplantation in the care of end-stage renal disease patients. Kidney Int 2007; 71:442.
- Delmonico FL, McBride MA. Analysis of the wait list and deaths among candidates waiting for a kidney transplant. Transplantation 2008; 86:1678.
- Merion RM, Ashby VB, Wolfe RA, et al. Deceased-donor characteristics and the survival benefit of kidney transplantation. JAMA 2005; 294:2726.
- Pascual J, Zamora J, Pirsch JD. A systematic review of kidney transplantation from expanded criteria donors. Am J Kidney Dis 2008; 52:553.
- Schold JD, Meier-Kriesche HU. Which renal transplant candidates should accept marginal kidneys in exchange for a shorter waiting time on dialysis? Clin J Am Soc Nephrol 2006; 1:532.
- Molnar MZ, Streja E, Kovesdy CP, et al. Age and the associations of living donor and expanded criteria donor kidneys with kidney transplant outcomes. Am J Kidney Dis 2012; 59:841.
- Mezrich JD, Pirsch JD, Fernandez LA, et al. Differential outcomes of expanded-criteria donor renal allografts according to recipient age. Clin J Am Soc Nephrol 2012; 7:1163.
- Winkelmayer WC, Mehta J, Chandraker A, et al. Predialysis nephrologist care and access to kidney transplantation in the United States. Am J Transplant 2007; 7:872.
- Danovitch GM, Cecka JM. Allocation of deceased donor kidneys: past, present, and future. Am J Kidney Dis 2003; 42:882.
- Leichtman A, Stegall M. A dynamic period of reappraisal and innovation in kidney transplantation practice and policies. NephSAP 2008; 7:1.
- Pilmore H. Cardiac assessment for renal transplantation. Am J Transplant 2006; 6:659.
- K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005; 45:S1.
- Ohtake T, Kobayashi S, Moriya H, et al. High prevalence of occult coronary artery stenosis in patients with chronic kidney disease at the initiation of renal replacement therapy: an angiographic examination. J Am Soc Nephrol 2005; 16:1141.
- Gill JS, Ma I, Landsberg D, et al. Cardiovascular events and investigation in patients who are awaiting cadaveric kidney transplantation. J Am Soc Nephrol 2005; 16:808.
- Kasiske BL, Malik MA, Herzog CA. Risk-stratified screening for ischemic heart disease in kidney transplant candidates. Transplantation 2005; 80:815.
- Fishbane S. Cardiovascular risk evaluation before kidney transplantation. J Am Soc Nephrol 2005; 16:843.
- Stack AG, Martin DR. Association of patient autonomy with increased transplantation and survival among new dialysis patients in the United States. Am J Kidney Dis 2005; 45:730.
- Kutner NG, Zhang R, Bowles T, Painter P. Pretransplant physical functioning and kidney patients' risk for posttransplantation hospitalization/death: evidence from a national cohort. Clin J Am Soc Nephrol 2006; 1:837.
- Ikizler TA. Resolved: being fat is good for dialysis patients: the Godzilla effect: pro. J Am Soc Nephrol 2008; 19:1059.
- Schold JD, Srinivas TR, Guerra G, et al. A "weight-listing" paradox for candidates of renal transplantation? Am J Transplant 2007; 7:550.
- THE ACTIVE AND INACTIVE LIST
- Gender and blood group
- Renal diagnosis
- LISTING PRACTICES
- WAITING TIME
- Previously transplanted and presensitized patients
- DEATH ON THE WAITING LIST
- Expanded donor kidneys
- ACCESS TO THE WAITING LIST
- UNPREDICTABILITY OF ALLOCATION
- HEALTH MAINTENANCE
- Preventive health measures
- Cardiovascular testing
- Physical activity
- Obesity and weight loss
- INFORMATION FOR PATIENTS