Sex/Gender Disparities in Preemptive Referrals for Kidney Transplantation

Introduction: Sex/gender inequities persist in access to kidney transplantation. Whether differences in preemptive referral (i.e., referral before dialysis start) explain this inequity remains unknown. Methods: All adults (aged 18-79 years; N 1 / 4 44,204) initiating kidney replacement therapy (KRT; dialysis or transplant) in Georgia (GA), North Carolina (NC), or South Carolina (SC) between 2015 and 2019 were identified from the United States Renal Data System (USRDS). Individuals were linked to the Early Steps to Kidney Transplant Access Registry (E-STAR) to obtain data on preemptive referral and followed-up with through November 13, 2020, for outcomes of waitlisting and living donor transplant. Logistic regression assessed the association between sex/gender and likelihood of preemptive referral among all KRT patients. Cox-proportional hazards assessed the association between sex/gender and waitlisting or living donor among preemptively referred patients. Results: Overall, men and women were similarly likely to be preemptively referred (odds ratio [OR]: 0.99 [0.95-1.04]). Preemptively referred women (vs. men) were, on average, younger and with fewer comorbidities. There were no sex/gender differences in waitlisting once patients were preemptively referred (hazard ratio [HR]: 0.97 [0.91-1.03]); however, women (vs. men) who were preemptively referred remained 25% (HR: 0.75 [0.66-0.86]) less likely to receive a living donor transplant. Conclusion: In the Southeast US, men and women initiating KRT are similarly likely to be preemptively referred for a kidney transplant, and this appears, at least in part, to mitigate known sex/gender inequities in access to waitlisting, but not living donor transplant. Despite this, preemptively referred women, on average, had a more favorable medical pro fi le relative to preemptively referred men.