Intersecting social determinants create disparities in kidney transplant that include less access for women

Milda Saunders

BOSTON — Due to a variety of social determinants — including age, race and socioeconomic status — women have less access to kidney transplantation than men, according to a speaker at the American Transplant Congress.

In a presentation, Milda Saunders, MD, MPH, of the MacLean Center for Clinical Medical Ethics at the University of Chicago, defined access to transplantation as both the likelihood of being placed on the waitlist and of ultimately receiving a living donor transplantation.

“ESRD is biological and a result of complex social factors,” she said. “Women with ESRD have greater social disadvantages than their male counterparts. They’re more likely to be African American, more likely to be on Medicaid and more likely to report financial instability. They are also over-represented in poor and minority neighborhoods that multiple research studies have shown are associated with reduced access to high-quality dialysis facilities and reduced access to transplant referral.”

Despite the fact that at the start of hemodialysis men had more comorbidities than women, including cardiovascular disease, cancers and a history of smoking — all of which reduce their life expectancy and mitigate the potential survival benefit to be gained from the transplant — women were significantly less likely to be placed on the waitlist, according to a variety of cited studies.

“Men receive transplants out of proportion to their level of benefit,” Saunders said.

Furthermore, not only were women less likely to be placed on the waitlist, they were also less likely to have had discussions with kidney transplant medical professionals about that possibility and were more likely to be reported as unsuitable for transplant.

Age further compounded the observed gender disparity as women in the 46- to 55-year age range were 33% less likely to be waitlisted than their male counterparts. This gap increased to 60% less likely for women older than 75 years.

Saunders also noted that although women account for 62.5% of living donors, men received 63% of living donor kidney transplants in 2017 compared with 37% for women.

Narrowing focus to within the family, of those deemed acceptable to donate a kidney, 36% of wives continued to donate compared with 6.5% of husbands.

“On a societal level, we should look at what this means in terms of equity both within living donation overall and within marriages,” Saunders said.

To begin reducing disparities in transplant access, Saunders stressed the importance of considering race, gender, age, socioeconomic status and geography as intersecting and critical factors.

“We need to recognize that people have complicated lives,” she said. “We need to look at women in a more complicated way and accept that different issues may require different solutions.”

She also suggested increasing education of these disparities at both dialysis and transplant centers. Further, she said having increased representation of marginalized groups as part of the recipient evaluation process — and having the staff and physicians at the transplant centers accurately reflect the communities in which they serve — could initiate some positive change in the transplantation process.

She said, “We have the opportunity to improve outcomes both through our research and through patient, provider and center-based interventions.” – by Melissa J. Webb

Reference:

Saunders M. Access to care and social determinants in kidney transplantation. Presented at: American Transplant Congress. June 1-5, 2019; Boston.

Disclosure: Saunders reports no relevant financial disclosures.