Geographic Variation in Sex Disparities in Access to the Kidney Transplant Waitlist Open Access
Bowers, Margo (Spring 2024)
Published
Abstract
In 2021, over 800,000 individuals were living with end-stage kidney disease (ESKD) in the United States.1 ESKD patients require treatment to survive, and despite clear benefits of transplant over dialysis for many people with ESKD, only 4% of patients on dialysis in 2021 received a transplant.1 In this context of scarce organ supply, inequities in access to kidney transplantation exist. In particular, women with ESKD are ~20% less likely to be waitlisted for a kidney transplant,1 and whether this disparity differs regionally in the US remains unknown. Identifying geographic ‘hot spots’ where sex inequities are greatest (and least) may shed light on potential mechanisms and allow for targeted interventions. In this retrospective cohort study, we identified adults (18-90) initiating kidney replacement therapy (KRT) between 2015-2019 from the United States Renal Disease System (USRDS). ‘Sex’ was ascertained from the Centers for Medicare & Medicaid Services Medical Evidence Form (CMS-2728), and geography was defined by the 18 End-Stage Renal Disease (ESRD) Networks managing ESKD patient care in the US. The primary outcome was time to waitlisting, measured as time between initiating KRT and being waitlisted. Cumulative incidence of waitlisting was estimated overall, by sex, and by ESRD Network with death as a competing risk. Coxproportional hazard models assessed the association of sex and time to waitlisting by ESRD Network, with a partially adjusted model controlling for clinical factors and a fully adjusted model controlling for both clinical and non-clinical factors. The cumulative incidence of waitlisting for men and women at study end were 22.4% and 18.5%, respectively. Overall, women were 17% less likely to be waitlisted compared to men (Crude HR: 0.83 [95% CI: 0.82, 0.84]) and ranged from women being 10-22% less likely in Networks 16 (states of AK, ID, MT, OR) and 14 (Texas), respectively. This disparity ranged from 5-17% in partially adjusted models, and from 2-19% in the fully adjusted models. Though ubiquitously disadvantageous to women across the US, this sex disparity is not explained by clinical factors and is notably stronger in certain regions. Future research should investigate mechanisms in which place of residence contributes to this disparity
Table of Contents
I. Literature Review...1
II. Introduction...14
III. Methods...15
IV. Results...20
V. Discussion...33
VI. References... 39
VII. Supplementary...43
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