J. Hogan has documented that he has no relevant financial relationships to disclose or conflict of interest to resolve.
Why do girls with end-stage renal
disease wait longer for
transplantation than boys?Dr Julien Hogan
Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France
REIN Registry, France
On behalf of the ESPN/ERA-EDTA Registry
Introduction
– Study of inequality in access to renal transplantation:
• 852 references on Pubmed
– In Europe such inequalities have been found:
• Between countries1
• Between centers2,3
• Between patients : age, racial disparities4,5, socio-economic
status, educational level6
…… AND GENDER7,8,9
[1] Harambat et al. AJT 2013; [2] Oniscu et al. BMJ 2003; [3] Hogan et al. NDT 2014
[4] Furth et al. Pediatrics 2000; [5]Soucie et al. AJKD 1992; [6] Schaeffner et al. AJKD 2008
[7] Couchoud et al. Transplantation 2012; [8] Ravanan et al. BMJ 2010;
[9] Segev et al. JASN 2009
Introduction
• In both Europe and USA female gender has been
associated with:
– Lower access to transplantation
– Lower rate of registration on the waiting-list
– Longer time from start of dialysis to wait listing
• Factors contributing to these differences:
– Longer transplantation work-up1
– Lower willingness to undergo transplantation2
– Higher DSA level
[1] Alexander et al. JAMA 1998; [2] McCauley et al. AJKD 1997
Introduction
Objective:
To validate this gender inequality in access to renal transplantation
among children and to investigate its underlying causes
Methods
• Population
6454 patients <18, starting RRT between 01/01/2000 and 31/12/2012,
from 35 countries, recorded in the ESPN/ERA-EDTA registry
• Statistical analysis
•Time from RRT start to transplantation
Survival analysis: KM, Proportional Hazard
Frailty model
•Probability of pre-emptive transplantation
Hierarchical logistic regression
•Study of the time of follow-up prior RRT
T-test and Linear regression
Time to Access to Renal
Transplantation
Time to transplantation, death or recovery of renal function by gender
Median time from RRT to transplantation:
14.2 months in boys
16.5 months in girls
Time to Access to Renal
Transplantation
Access to transplantation by gender adjusted for age after excluding
preemptive transplantations
HR girls vs boys: 0.99, 95%CI: 0.92-1.06
Follow-up time before RRT
Median follow-up time:
23.0 months [2.4-68.6] in boys
14.4 months [0.6-53.6] in girls
Longer follow-up time is associated
with a higher chance of receiving
preemptive transplantation
OR 1.19 [1.15-1.24] per year
Possible explanations:
1. Girls are diagnosed later
1. Girls progress faster towards
ESRD
Conclusion (1)
• Gender difference in access to renal transplantation
is explained by a 23% decreased likelihood of
preemptive transplantation in girls.
• This difference is only partially explained by medical
factors such as age and primary renal disease
• A much shorter follow-up time prior RRT in girls
explains part of the gender difference in access to
renal transplantation
• A trend towards more rapid decline of eGFR in girls
Conclusion (2)
• Medical factors only partially explain gender
difference in access to transplantation
• Non-medical factors need to be considered:
– Patient willingness for early transplantation1
– Parents willingness to donate their kidney
– Health care professionals attitude towards pre-
emptive transplantation and living donor
transplantation2
– Fear of non-adherence to IS treatement3
…..
[1] McCauley et al. AJKD 1997; [2] Thamer et al. Transplantation 2001; [3] Chisholm et al. cJASN 2013
#
Transplant
Our Girls
Acknowledgments
• Cécile Couchoud
• Karlijn van Stralen
• Marjolein Bonthuis
• Jaap Groothoff
• Kitty Jager
• Franz Schafer
Acknowledgements
Albania D Shtiza Lithuania A Jankauskiene, B Pundziene
Austria R Kramar, R Oberbauer Malta V Saied-Conti
Belarus S Baiko, A Sukalo Moldova S Gatcan, O Berbeca, N Zaikova
Belgium K van Hoeck, F Collart, JM des Grottes Montenegro S Pavićević
Bosnia Herzegovina D Pokrajac Norway T Leivestad, A Bjerre
Bulgaria D Roussinov Poland A Zurowska, I Zagozdzon
Croatia D Batinić, M Lemac, J Slavicek Portugal C Mota, M Almeida, C Afonso
Czech Republic T Seeman, K Vondrak Romania G Mircescu, L Garneata
Denmark J Heaf Russia EA Molchanova, NA Tomilina, BT Bikbov
Estonia U Toots Serbia M Kostic, A Peco-Antic, B Spasojevic-Dimitrijeva,
G Milosevski-Lomic, D Paripovic, S Puric, D Kruscic
Finland P Finne, C Grönhagen-Riska Slovakia L Podracka, G Kolvek
France C Couchoud, M Lasalle, J Harambat Slovenia N Battelino, G Novljan, J Buturovic-Ponikvar
FYR of Macedonia E Sahpazova, N Abazi, N Ristoka Bojkovska Spain A Alonso Melgar and the Spanish Pediatric Registry
Germany F Schaefer, G von Gernsdorff, C Scholz,
B Tönshoff, K Krupka, B Höcker, L Pape
Sweden S Schön, KG Prütz, L Backmän, M Stendahl,
M Evans, B Rippe
Greece N Afentakis, A Kapogiannis, N Printza, C Stefanidis Switzerland G Laube, CE Kuehni, H Chehade, C Rudin
Hungary G Reusz Cs Berecki, A Szabó, T Szabó,
Zs Györke, E Kis
The Netherlands A Hoitsma, A Hemke, JW Groothoff, and all centres
participating in the RICH-Q study
Iceland R Palsson, V Edvardsson Turkey R Topaloglu, A Duzova
Italy B Gianglio, S Maringhini, C Pecoraro, S Testa,
E Vidal, E Verrina
Ukraine D Ivanov
Latvia V Strazdins, I Andersone United Kingdom R Pruthi, F Braddon, S Mannins, A Cassula, MD Sinha