C. Holscher1, C. Haugen1, K. Jackson1, A. Kernodle1, S. Bae1, J. Garonzik Wang1, D. Segev1 1Johns Hopkins University School Of Medicine,Baltimore, MD, USA
Introduction: While national policies direct organ allocation for waitlisted candidates, the decision to list a candidate for transplantation is made at the center- and patient-level. Historically, women have had decreased access to kidney transplantation (KT). We sought to investigate if gender disparities in access to KT have improved over time.
Methods: To explore temporal trends in access to KT, we studied 1,511,863 adults (age 18-99) with incident end-stage renal disease (ESRD) using the United States Renal Data System (USRDS) from 2000 to 2015. We divided the study period into four eras and compared characteristics of patients who were and were not listed for transplantation (Chi-square and Student’s t tests), and tested if waitlisting changed over time (Cuzick test of trend). We used Cox regression to determine the association between era and access to transplantation while controlling for candidate factors. As a sensitivity analysis to determine whether a differential risk of death before waitlisting impacted our inferences, we used a competing risk regression using the Fine and Gray method with a 5% random sample.
Results: The proportion of ESRD patients who were subsequently waitlisted decreased over time (13.2% in 2000-2003 to 8.7% in 2012-2015, p<0.001). Compared to those who were never waitlisted, waitlist registrants were less likely to be female (37% vs 45%, p<0.001), were younger (mean 50 vs. 66 years, p<0.001), were more likely to be African American (32% vs 28%, p<0.001), were more likely to be Hispanic (20% vs. 13%, p<0.001), and were more likely to have private insurance (38% vs. 17%) or be uninsured (13% vs 6%, p<0.001). After controlling for age, race, ethnicity, and prior insurance, men had similar access to KT over time (per 4-year era, aHR 1.00, 95% CI 1.00-1.01, p=0.6), while women had less access (aHR 0.80, 95% CI 0.20-0.81, p<0.001) that worsened with time (interaction p<0.001) (Figure). For context, in 2000-2003, women were 20% less likely to be waitlisted for kidney transplant (aHR 0.80, 95% CI 0.78-0.82, p<0.001), while in 2012-2015 this worsened to 22% less likely (aHR 0.78, 95% CI 0.76-0.80, p<0.001). Our sensitivity analysis using a competing risk regression also showed persistent gender disparities in waitlisting.
Conclusion: Despite decades of studies showing that women have less access to kidney transplantation, gender disparities in access to KT have not improved over time, rather they have worsened. Further focus and novel interventions are needed to improve access for female KT candidates.
