Sex Disparity in Deceased-Donor Kidney Transplant Access by Cause of Kidney Disease

Abstract

Background and objectivesWomen with kidney failure have lower access to kidney transplantation compared with men, but the magnitude of this disparity may not be uniform across all kidney diseases. We hypothesized that the attributed cause of kidney failure may modify the magnitude of the disparities in transplant access by sex.Design, setting, participants, & measurementsWe performed a retrospective cohort study of adults who developed kidney failure between 2005 and 2017 according to the United States Renal Data System. We used adjusted Cox models to examine the association between sex and either access to waitlist registration or deceased-donor kidney transplantation, and tested for interaction between sex and the attributed cause of kidney failure using adjusted models.ResultsAmong a total of 1,478,037 patients, 271,111 were registered on the waitlist and 89,574 underwent deceased-donor transplantation. The rate of waitlisting was 6.5 per 100 person-years in women and 8.3 per 100 person-years for men. In adjusted analysis, women had lower access to the waitlist (hazard ratio, 0.89; 95% confidence interval, 0.89 to 0.90) and to deceased-donor transplantation after waitlisting (hazard ratio, 0.96; 95% confidence interval, 0.94 to 0.98). However, there was an interaction between sex and attributed cause of kidney disease in adjusted models (P<0.001). Women with kidney failure due to type 2 diabetes had 27% lower access to the kidney transplant waitlist (hazard ratio, 0.73; 95% confidence interval, 0.72 to 0.74) and 11% lower access to deceased-donor transplantation after waitlisting compared with men (hazard ratio, 0.89; 95% confidence interval, 0.86 to 0.92). In contrast, sex disparities in access to either the waitlist or transplantation were not observed in kidney failure secondary to cystic disease.ConclusionsThe disparity in transplant access by sex is not consistent across all causes of kidney failure. Lower deceased-donor transplantation rates in women compared with men are especially notable among patients with kidney failure attributed to diabetes.

Sex and Gender in Glomerular Disease

“…Within nephrology, it is well documented that women with kidney failure have reduced access to the transplant waiting list and to deceased donor transplantation. 91 The reasons for this are complex and might reflect disparities between outcome measures discussed earlier. 10 Serum creatinine is a commonly used indicator of kidney function but is not directly comparable between the sexes.…”

Sex and gender disparity in kidney transplantation: Historical and future perspectives

“…found an interaction between sex and the etiology of kidney disease, where women with type 2 diabetes had a 27% lower access to the waitlist compared to men. This disparity was more pronounced for older women and was non‐existent in women with kidney failure attributed to cystic disease 28 …”

Disparities in Access to Preemptive Repeat Kidney Transplant: Still Missing the Mark?

“…24 It is known that compared with males, females have reduced referral for kidney transplant, less activation on the waitlist once referred, are less likely to undergo transplant once activated [25][26][27] , have pregnancy-induced presensitization, as well as postulated attitudes that women may be perceived by care providers to be less eligible for transplant than men, even with similar or reduced comorbidity burden. 28 Potential explanations for more first and repeat PKT in females than males may include a faster rate of progression to ESKD in males 29 that precludes appropriate preparation for PKT. However, we found that males undergo PKT at a significantly higher eGFR than females do.…”