Older Women Lag Behind Men in Access to Kidney Transplants

Older Women Lag Behind Men in Access to Kidney Transplants

By Todd Neale, Staff Writer, MedPage Today
Published: January 07, 2009

Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.

BALTIMORE, Jan. 7 -- Women 55 or younger who need a kidney transplant have as much access to an organ as do men, but then a gender disparity begins to emerge, researchers here found.

Compared with men, younger women had equal access to the cadaver-donor waiting list and to live-donor transplantation, but their access declined with increasing age (P0.001), Dorry Segev, M.D., of Johns Hopkins, and colleagues reported online in the Journal of the American Society of Nephrology.

Women ages 56 to 65 had 15% less access to transplantation, those ages 66 to 75 had 29% less access, and those older than 75 had 59% less access than men of similar age.

The investigators were unable to explain why such a disparity exists, but speculated that it might be a result of perceptions of physicians, patients, or patients' families.
Action Points

* Explain to interested patients that this study found that the gender disparity in access to kidney transplantation does not affect all age groups.

* Point out that the study found that among patients with comorbidities such as diabetes, women had less access to transplantation than men with the same condition, even among the younger age group.

"Older and sicker women may be more likely to be perceived by their providers or to perceive themselves as frail and unable to withstand a major surgical procedure (as compared with men of the same characteristics)," they said.

The findings could not be explained by differences in survival benefit, which was either equivalent in both sexes or higher among women for each age group, said the investigators.

Although the gender disparity had been identified previously, the contribution of age and comorbidity had not been well studied, they added.

To explore the issue, they evaluated data from 563,197 adult patients with end-stage renal disease (mean age 62.5 for men and 63.9 for women) from the U.S. Renal Data System and the United Network for Organ Sharing.

Overall, 14.4% of the patients joined the cadaver-donor waiting list and 1.7% received a live-donor transplant without joining the list. The rest (83.9%) never joined the list or received a transplant; half of these patients died and half continued on dialysis.

For all age groups combined, women had 11% less access to transplantation than men.

The disparity in access became apparent only in patients older than 55, who receive about 30% of all kidney transplants. Compared with men, the relative risks of women gaining access to transplantation stratified by age were:

* Ages 18 to 55: RR 1.01 (no confidence interval provided)
* Ages 56 to 65: RR 0.85 (95% CI 0.83 to 0.87)
* Ages 66 to 75: RR 0.71 (95% CI 0.68 to 0.75)
* Ages 75 and older: RR 0.41 (95% CI 0.34 to 0.50)

Once women were placed on the deceased-donor waiting list, however, there was no significant difference in the amount of time they waited for a transplant compared with men (P=0.1).

This differs from disparities in kidney transplantation among black and obese patients, who have a decreased likelihood of receiving a transplant even after getting on the list, the researchers said.

Among patients with comorbidities, women had less chance of receiving access to transplantation than men with the same conditions, even among the younger age group and despite similar survival benefit.

For example, women ages 18 to 45 who had diabetes had 6% less access to transplantation than diabetic males in the same age group (RR 0.94, 95% CI 0.91 to 0.97, P0.001).

The disparity related to comorbidities was even greater in the older age groups.

For example, women older than 75 who had diabetes had 68% less access (RR 0.32, 95% CI 0.24 to 0.43) than men.

"This study suggests that there is no disparity in access to transplantation for women in general but rather a marked disparity in [access] for older women and women with comorbidities," the researchers said.

Further studies are needed to determine whether physicians are less likely to refer older women for transplantation or whether older women are less likely to seek a referral.

The authors acknowledged several limitations of the study, including the lack of information on comorbidity severity, psychosocial factors, cognitive function, medication compliance, dialysis facility ownership, and timing of predialysis care.

In addition, they said, there was no information on panel reactive antibody levels, which can be raised by pregnancy and influence the chances of having a positive cross-match with a potential live donor.

The study was supported in part by a Health Resources and Services Administration contract.

The authors made no financial disclosures.

Primary source: Journal of the American Society of Nephrology
Source reference:
Segev D, et al "Age and comorbidities are effect modifiers of gender disparities in renal transplantation" J Am Soc Nephrol 2009; DOI: 10.1681/ASN.2008060591.
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