Sex Differences in the Recognition, Monitoring, and Management of CKD in Health Care: An Observational Cohort Study

Abstract

IntroductionReported sex differences in the etiology, population prevalence, progression rates, and health outcomes of people with CKD may be explained by differences in health care.MethodsWe evaluated sex as the variable of interest in a health care–based study of adults (n=227,847) with at least one outpatient eGFR<60 ml/min per 1.73 m2 measurement denoting probable CKD in Stockholm from 2009 to 2017. We calculated the odds ratios for diagnosis of CKD and provision of RASi and statins at inclusion, and hazard ratios for CKD diagnosis, visiting a nephrologist, or monitoring creatinine and albuminuria during follow-up.ResultsWe identified 227,847 subjects, of whom 126,289 were women (55%). At inclusion, women had lower odds of having received a diagnostic code for CKD and were less likely to have received RASi and statins, despite having guideline-recommended indications. In time-to-event analyses, women were less likely to have received a CKD diagnosis (HR, 0.43; 95% CI, 0.42 to 0.45) and visited a nephrologist (HR, 0.46; 95% CI, 0.43 to 0.48) regardless of disease severity, presence of albuminuria, or criteria for referral. Women were also less likely to undergo monitoring of creatinine or albuminuria, including those with diabetes or hypertension. These differences remained after adjustment for comorbidities, albuminuria, and highest educational achievement, and among subjects with confirmed CKD at retesting. Although in absolute terms all nephrology-care indicators gradually improved over time, the observed sex gap persisted.ConclusionsThere were profound sex differences in the detection, recognition, monitoring, referrals, and management of CKD. The disparity was also observed in people at high risk and among those who had guideline-recommended indications.

Sex Disparities in the Quality of Care for CKD

“…Although these findings were observed in a Swedish population, a previous review by Carrero et al 7 highlights numerous disparities in processes and outcomes of care in other countries. The findings of Swartling et al 2 were observed despite reporting of eGFR by clinical laboratories in the later years of the study. Larger disparities might be expected if clinical laboratories report only serum creatinine, which is lower in women than in men with the same measured GFR.…”

“…Currently, kidney biopsy is the only clinical tool to assess the extent of tubulointerstitial injury, because GFR correlates poorly with severity of nephrosclerosis. 2 Therefore, identification of novel biomarkers of kidney health, such as markers of tubular dysfunction or injury measurable in urine or blood specimens, has the potential to revolutionize the approach to diagnosis and management of CKD.…”

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to be independent of kidney function and diabetes status, leading to benefits across a wide range of GFRs. 10 The rationale for this study by Bergling et al 2 emerges from the second study of the series where phlorizin, a nonselective SGLT inhibitor, reduced peritoneal glucose absorption in the same rat model. 11 The third study was conducted to distinguish if these effects were meditated by SGLT1 inhibition (considering the lack of effect with empagliflozin) or GLUT inhibition by the phlorizin metabolite, phloretin.

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“…Swartling et al 2 use data from the Stockholm Creatinine Measurements project derived from a health care provider that provides care to 20%–25% of Sweden’s population. In a retrospective cohort study of adult subjects from 2009 to 2018, serum or plasma creatinine was used to calculate eGFR.…”

“…Interpreting comparisons of outcomes of CKD in women versus men is inherently difficult because of numerous differences between them; for example, women tend to have a longer life expectancy than men and thus, may be more likely to develop CKD. In this issue of JASN , Swartling et al 2 compare processes of care for CKD in men and women in a large, insured population in Stockholm.…”