Gender disparities in kidney transplant access and outcomes: a population-based analysis

Abstract

Background. Kidney transplantation is seen as a better treatment option in end-stage kidney disease (ESKD) because it offers greater longevity as well as quality of life. Access to kidney transplantation and post-transplantation outcomes is generally hindered by gender disparities. Women are underrepresented as kidney recipients but overrepresented as living donors. Gender disparities in kidney transplantation exist as a result of various factors, such as biological and sociocultural one, including sensitization from prior pregnancies, biological differences in the immune system, or gendered patterns of health care access or referral. Women receive fewer transplant referrals, face delays in evaluations, and obtaining encouragement for transplant compared with men. Materials and methods. This population-based study uses the Early Steps to Transplant Access Registry data and focuses on ESKD patients from Georgia, North and South Carolina. It examines gender differences across the full transplant care continuum, from referral to post-transplant outcomes. We statistically adjusted for clinical prognostic variables and demographic factors to evaluate the independent contribution of gender on transplant access and outcomes. Results. Our examination shows that women with ESKD are significantly less likely to be listed or receive a kidney transplant compared to men, even after controlling for other variables. The requirements persist throughout the transplant process, and the inequities are evident at every stage. While biologically related considerations of risk (graft rejection) and differences in metabolism of immunosuppressive medications likely partially explain some variance in outcomes, gender-related social determinants (e.g., provider bias) and systemic inequities generally explain more variance in the access gap for women, by comparison. It is also important to note new emerging challenges of great concern, such as the under-researched healthcare needs of transgender people, and the impact of COVID-19 on transplant recipients that compound gender inequities related to access to transplantation. Conclusions. This study highlights the pressing need to identify and address gender equity considerations in kidney transplantation decisions. Although there may be clinical justification for gender inequities, these issues emanate predominantly from modifiable sociocultural and institutional factors. Transplantation systems have not officially considered sex- and gender-sensitive means to eliminate barriers to access. Immediate policy intervention, education, and support are needed to ensure equitable access and equity of outcomes for all people, especially those from diverse gender identities.