Gender Disparities in Access to Kidney Transplantation

Why do nephrologists seek kidney transplantation for their patients? Overall, people with kidney transplants live longer than those treated with dialysis. Quality of life is improved in those receiving a transplant compared with those on the waitlist. Fertility is restored with transplantation, and pregnancy outcomes are vastly improved in the setting of a well-functioning kidney allograft compared with treatment with dialysis. However, despite these distinct advantages associated with kidney transplantation, women living with kidney disease around the world remain under-referred, under-waitlisted, and under-transplanted compared with men while at the same time comprising the majority of living kidney donors.¹ This begs the question: What are the barriers to gender equity in kidney transplantation?

While sex-related biological considerations, including higher risk of sensitization due to immune-related factors that are amplified in the setting of previous pregnancy, have been shown to play a role in lower transplantation rates in women compared with men, to date, less attention has been directed toward gender-related factors. Furthermore, while in isolation sex-based differences in immune sensitization may explain prolonged time to transplant among women active on the waitlist, it does not explain the lower transplant referral and waitlist activation rates pervasive among women compared with men. Gender is a complex inter-relationship between the socially constructed roles, behaviors, and identity of an individual that influence how people perceive themselves and others, as well as their actions and interactions. Further germane to the present study, institutionalized gender refers to the distribution of power and resources within society, which further affects the decision to discuss transplantation options, refer for evaluation, accept on the waitlist, and ultimately proceed with kidney transplantation.

In this issue of CJASN, Natale and colleagues² describe the perspectives of 51 general and transplant nephrologists from 22 countries on gender disparities in kidney transplantation and identify three themes relating directly to the concept of gender roles and relations as well as institutionalized gender: caregiving, stereotyping and stigma, and social disadvantage and vulnerability. These data represent an important recognition by the nephrology workforce of sociocultural obstacles to the gold standard treatment of kidney failure.

The authors report that nephrologists consistently perceived that caregiving roles were central for women across all countries, cultures, and socioeconomic strata. Recognition of the role women play in caregiving and home duties was a strong theme, with study participants identifying a desire in women patients to avoid burdening family members as well as an inability to delegate family commitments such as childcare, thus impairing their ability to start the transplantation process. By contrast, respondents perceived that this caregiving role contributed to a willingness of women to donate a kidney to a male partner or relative, who was commonly the primary earner.

The study findings that lower education and financial resources, coupled with less familial and societal support, contribute to women's limited access to kidney transplantation are in keeping with the literature. Poor language proficiency has been associated with poor self-reported health in women but not men, with implications for health information and care. Limited health literacy is common in CKD, especially among individuals with low socioeconomic status and of non-White race; however, there is lower prevalence of low health literacy among the transplanted population.³ Whether this reflects selection of patients with higher health literacy or represents a direct effect of health literacy on access to transplantation is unknown, but the influence of low health literacy is likely to have a disproportionate effect on women's opportunities for kidney transplantation.

Importantly, most of the nephrologists interviewed were from high-income countries and interviews were conducted in English and German, which may limit generalizability because the perceptions described by study participants may not be reflective of all those in the worldwide nephrology health care workforce. However, there was some representation from nephrologists from low- and middle-income countries, signaling the study's goal of a global perspective on gender inequities in kidney transplantation. As acknowledged by the authors, while these themes are likely to vary by sociocultural and regional norms, gender disparities in access to transplantation are more marked in less privileged populations, which may signal an underestimate in this study of gendered social inequities limiting access to kidney transplantation, particularly in low-resource settings or in stronger patriarchal societies.

The fact that this study represents the perceptions of nephrologists, as opposed to those of women living with kidney disease, deserves mention. An important limitation of this study is the focus on nephrologists' perception of patient-level barriers to kidney transplantation, without study of potential nephrologist-level biases. It bears mention that nephrologists' perceptions of gender differences in barriers to kidney transplantation have the potential to influence (consciously or subconsciously) decision making regarding transplant referral. Studies in primary care have demonstrated that perceived (not direct) patient pressure independently influences physician prescribing, referral, and investigation, even when accounting for medical indication.⁴ Therefore, might a perception that men with CKD have fewer sociocultural barriers to (and a greater expectation of) receiving a kidney transplant likewise influence nephrologist transplant referral patterns? This has not been explored, but is an important consideration. The perceived barriers described by Natale et al. should not necessarily dissuade transplant referral, and yet, nephrologist nonreferral is a major roadblock for women accessing transplant globally, including in high-income countries with socialized health care. Compared with men, women with kidney failure are 45% less likely to discuss kidney transplant with their health care provider; this gap only widens with advancing age.⁵ Whether nephrologists adopt a paternalistic approach as to who might benefit from such discussions (and subsequent transplant referral) on the basis of their perception of who may or may not have the capacity to move forward with kidney transplant may further fuel gender inequities.

Previous work has shown that nephrology providers demonstrate limited knowledge of their patients' priorities.⁶ In an American study of older adults with advanced non–dialysis-dependent CKD, patients prioritized maintaining independence above all else, while nephrology providers' perceptions of their patients' top health outcome priorities were only correct in a minority of cases. Whether this concordance, or lack thereof, differed by gender of the person living with CKD or the provider was not reported. Documented gender-specific physician communication and patient behavior differences have raised the question of whether gender-concordant relationships (e.g., both patient and provider share the same gender identity) might affect patient experiences and outcomes, particularly in the setting of a language barrier, although studies are conflicting. Of note, in a study using a standardized survey in a primary care setting to assess communication experiences with health care providers, there were no significant effects of patient–physician gender concordance, although female patients reported lower patient experience scores compared with male patients.⁷ This may suggest that physician (independent of physician gender) behavior differs depending on the gender of the patient or that the gender of the patient influences expectations of the physician. From a nephrology perspective, a recent Canadian survey study found that while kidney transplant referral practices varied among health care providers, no differences by candidate gender in likelihood of referral were noted in hypothetical case scenarios.⁸ While we are not aware of studies specific to nephrology examining whether patient experiences or outcomes differ related to physician–patient gender concordance, it is worth noting that roughly equal numbers of women and men nephrologists were included as part of the present study, although the gender of the nephrologist was not accounted for in the analysis of results. Interestingly, the Canadian survey study noted that women nephrologists were less likely to refer medically complex patients for transplantation while men nephrologists were less likely to refer frail patients.⁸ However, whether these findings translate to clinical practice is unknown.

Acknowledging the effect of these gender-related societal drivers, and in addition to previously documented sex-specific factors affecting allograft outcomes, achieving gender equity in kidney transplantation will not be a quick fix. Increased attention to gender inequities is important, but purposeful action as outlined by Natale and colleagues is urgently required using a multifaceted approach. We further suggest that in the preclinical realm, increasing female sex and diverse gender representation in all kidney transplantation research and reporting of sex and/or gender disaggregated data are additional crucial steps toward gender equity.⁹ In addition to acknowledging the obstacles to full participation in discussions and referral for kidney transplantation in women living with kidney disease, concrete steps using gender-sensitive communication tools and strategies are required, similar to those recommended for increasing kidney research engagement with women and gender-diverse populations.¹⁰

So, in answer to the question: Why do nephrologists seek kidney transplantation for their patients? This is the wrong question because we already know it is the best treatment we currently have for persons living with or nearing kidney failure. Natale and colleagues have shown us that we are fully aware of the barriers to women accessing kidney transplantation. A better question is: What are we doing as a global nephrology community to ensure equitable access to kidney transplantation for all individuals living with CKD, irrespective of gender or other sociocultural factors? This is the real question we need to be asking.

Disclosures

S.B. Ahmed reports advisory or leadership roles as Canadian Medical Association Journal Governance Council Member (volunteer position), Chair of Canadian Institutes of Health Research Institute of Gender and Health Advisory Board (volunteer position) (http://www.cihr-irsc.gc.ca/e/50746.html), and President-Elect of Organization for the Study of Sex Differences (https://www.ossdweb.org/) (volunteer position). A.J. Vinson reports consultancy for and research funding from Paladin Labs Inc.

Funding

None.

Author Contributions

Conceptualization: Sofia B. Ahmed, Amanda J. Vinson.

Writing – original draft: Sofia B. Ahmed.

Writing – review & editing: Sofia B. Ahmed, Amanda J. Vinson.