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

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.

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.

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).

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.