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

Results

Time to Access to Renal

Transplantation

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

Access to pre-emptive renal

transplantation

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

eGFR evolution before RRT

Explaining Gender Effect

Explain 70% of the gender difference

in access to renal transplantation

?

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