Sex and Intersectional Disparities in Access to Deceased Donor Kidney Transplantation: A 17-Year Population-Based Cohort Study.

BACKGROUND

While sex disparities in access to transplant have been shown in a number of countries, the ways additional measures of disadvantage, such as intersectional and clinical disadvantage, influence sex-based disparities is less well understood. Access to transplant by sex or intersectional disadvantage has not been studied in Australia.

METHODS

We conducted a population-based cohort study of incident dialysis patients (2006-2023) using Australia & New Zealand Dialysis and Transplant Registry data. Cox proportional hazards models, interaction analyses and competing-risk approaches were used to evaluate associations between sex, waitlisting and deceased donor transplantation, adjusting for intersectional and clinical characteristics.

RESULTS

Among 47 884 incident dialysis patients contributing 147 510 person-years of follow-up, females were 19% less likely to be waitlisted than males (aHR 0.81, 95% CI 0.77-0.84). Sex-based disparities were greatest among females with intersectional disadvantage, including ethnic minority status (Aboriginal & Torres Strait Islander: aHR 0.57, 95% CI 0.49-0.66), diabetic kidney disease (aHR 0.61, 95% CI 0.56-0.67), having ≥ 3 comorbidities (aHR 0.66, 95% CI 0.56-0.79) and obesity (aHR 0.69, 95% CI 0.65-0.75), compared to male peers. Once waitlisted, females and males had similar likelihood of deceased donor transplantation (aHR 1.04, 95% CI 0.99-1.10) and comparable waitlist mortality (aHR 0.91, 95% CI 0.76-1.08).

CONCLUSIONS

Females in Australia experience substantially reduced access to the kidney transplant waitlist, with the greatest inequities affecting those facing overlapping social and/or clinical disadvantage. The absence of sex-disparity after waitlisting indicates that inequities arise earlier in the referral and evaluation pathway. Interventions to improve equity must target these upstream stages and address intersecting drivers of disadvantage.