Sex and Gender Disparities in Living Kidney Donation: A Scoping Review

A Single-Center Retrospective Study to Identify Causes of Sex Differences in the Living Kidney Donor Evaluation Process

Key Points

Background

Multiple studies have shown that female volunteers are living donors (LDs) for kidney transplantation at higher rates than male volunteers. However, the underlying reasons for this observation are not well understood. We examined the LD evaluation process to determine the point at which sex imbalance arises. On the basis of a previous study, we hypothesized that both sexes are equally likely to become approved as LDs, but female volunteers are more likely to follow through with donation.

Methods

This is a single-institution retrospective chart review of self-referrals for LD evaluation between January 2009 and December 2022. Self-referrals were identified using the Organ Transplant Tracking Record database and cross-referenced with billing data. Exclusion at each stage of evaluation was recorded and compared between sexes using log binomial regression; unadjusted and adjusted (for donor age, race, ethnicity, relationship to recipient, and recipient sex) risk ratios with 95% confidence interval were determined.

Results

One thousand eight hundred sixty-one self-referrals were reviewed, including 1214 female (65.2%) and 647 male (34.8%) volunteers, resulting in 146 approvals and 125 donations (76/125, 60.8% female, 49/125, 39.2% male). Adjusted risk ratios indicated no significant differences between sexes in completing medical and/or psychosocial workup, having medical and/or psychosocial contraindications, being approved for donation, and proceeding with donation. The top medical contraindications for both sexes were obesity, hypertension, and nephrolithiasis.

Conclusions

Female overrepresentation among LDs is likely due to the 1.9 times higher rate of self-referral for evaluation. After this point, both sexes were equally likely to complete workup, be approved, and follow through with donation. Increased efforts to engage male volunteers at the initial self-referral stage has the potential to expand access to LD kidney transplantation.

Podcast

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Systemic Factors Contributing to Gender Differences in Living Kidney Donation: A Systematic Review and Meta-Synthesis Using the Social-Ecological Model Lens

INTRODUCTION

The field of living kidney donation is profoundly gendered contributing to a predominance of women, mothers, and wives as living kidney donors (LKDs). Individual factors have traditionally been emphasized, and there is a limited appreciation of relational, community, and sociocultural influences in decision-making. We aimed to comprehensively capture existing evidence to examine the relative importance of these factors.

METHODS

This was a systematic review of existing literature that has explored the motivation of different genders to become LKDs. Of the 3,188 records screened, 16 studies from 13 counties were included. Data were synthesized thematically using the Social-Ecological Model lens.

RESULTS

At the individual level, themes related to intrinsic motivation; thoughtful deliberation; and attitudes, fears, and beliefs; however, evidence demonstrating differences between men and women was minimal. Greater variation between genders emerged along the relational (coercion from family/network, relationship with the intended recipient, self-sacrifice within the family unit, and stability/acceptance within family); community (economic value and geographic proximity to recipient); and sociocultural (gendered societal roles, social norms and beliefs, social privilege, and legislation and policy) dimensions. The relative importance of each factor varied by context; cultural components were inferred in each study, and economic considerations seemed to transcend the gender divide.

CONCLUSIONS

A complex interplay of factors at relational, community, and sociocultural levels influences gender roles, relations, and norms and manifests as gender disparities in living kidney donation. Our findings suggest that to address gender disparities in living donation, dismantling of deep-rooted systemic contributors to gender inequities is needed.

[Sex differences in hepatobiliary and transplantation surgery]

Gender-specific differences in hepatobiliary and transplantation surgery are decisive for the diagnosis, treatment and long-term outcomes. Men exhibit a higher risk of late recurrences and cancer-specific death after liver cancer resection. The emphasis on screening recommendations and ensuring equal access to treatment options are vital to minimize disparities. In kidney and liver transplantations, women are less frequently listed and endure longer waiting times, while men dominate the waiting list. Gender-specific disparities in drug compatibility necessitate differentiated dosing. Further studies are needed to ensure equity in transplantation treatment. Individualized treatment considering these differences can enhance treatment outcomes and the quality of life of patients.

Post-Donation Evaluation: Emotional Needs for Social Connection and Social Support among Living Kidney Donors-A Systematic Review

INTRODUCTION

Evaluation of post-nephrectomy social health in living kidney donors is essential. This systematic review examines their emotional need for social relatedness post-donation.

METHODS

Following the PRISMA guidelines, we systematically searched Scopus, CINAHL, and PsycINFO.

RESULTS

Among the screened records, 32 quantitative and 16 qualitative papers met the inclusion criteria. Quantitative research predominantly utilized questionnaires featuring generic items on social functioning. However, a minority delved into emotional and social dimensions, aligning with qualitative studies emphasizing the importance of social connection and perceived social support post-donation. Specifically, post-donation changes in connecting with others encompass a sense of belongingness, heightened autonomy, shifts in concern for the recipient's health, and continued care by shielding the recipient from personal health issues. Social acknowledgment and social support from both close and extended networks are reported as relevant for recovery after nephrectomy.

DISCUSSION

These findings underscore the necessity for targeted measures of emotional needs and social functioning to effectively assess post-donation adjustment. They also inform the identification of key health themes for kidney donor Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs) questions.

Relationships, race/ethnicity, gender, age, and living kidney donation evaluation willingness

Racial/ethnic and gender disparities in living donor kidney transplantation are large and persistent but incompletely explained. One previously unexplored potential contributor to these disparities is differential willingness to donate to recipients in specific relationships such as children, parents, and friends. We collected and analyzed data from an online sample featuring an experimental vignette in which respondents were asked to rate their willingness to donate to a randomly chosen member of their family or social network. Results show very large differences in respondents' willingness to donate to recipients with different relationships to them, favoring children, spouses/partners, siblings, and parents, and disfavoring friends, aunts/uncles, and coworkers. Evidence suggesting an interactive effect between relationship, respondent race/ethnicity, respondent or recipient gender, was limited to a few cases. At the p < 0.05 level, the parent-recipient gender interaction was statistically significant, favoring mothers over fathers, as was other/multiracial respondents' greater willingness to donate to friends compared to Whites. Additionally, other interactions were significant at the p < 0.10 level, such as Hispanics' and women's higher willingness to donate to parents compared to Whites and men respectively, women's lower willingness to donate to friends compared to men, and Blacks' greater willingness to donate to coworkers than Whites. We also examined differences by age and found that older respondents were less willing to donate to recipients other than their parents. Together these results suggest that differential willingness to donate by relationship group may be a moderately important factor in understanding racial/ethnic and gender disparities in living donor kidney transplantation.

Understanding the dynamics of deceased organ donation and utilization in Colombia

Objective

To obtain a comprehensive overview of organ donation, organ utilization, and discard in the entire donation process in Colombia.

Methods

A retrospective study of 1 451 possible donors, distributed in three regions of Colombia, evaluated in 2022. The general characteristics, diagnosis, and causes of contraindication for potential donors were described.

Results

Among the 1 451 possible donors, 441 (30.4%) fulfilled brain death criteria, constituting the potential donor pool. Families consented to organ donation in 141 medically suitable cases, while 60 instances utilized legal presumption, leading to 201 eligible donors (13.9%). Of those, 160 (11.0%) were actual donors (in whom operative incision was made with the intent of organ recovery or who had at least one organ recovered). Finally, we identified 147 utilized donors (10.1%) (from whom at least one organ was transplanted). Statistically significant differences were found between age, sex, diagnosis of brain death, and donor critical pathway between regions. A total of 411 organs were transplanted from 147 utilized donors, with kidneys being the most frequently procured and transplanted organs, accounting for 280 (68.1%) of the total. This was followed by 85 livers (20.7%), 31 hearts (7.5%), 14 lungs (3.4%), and 1 pancreas (0.2%). The discard rate of procured deceased donors was 8.1%.

Conclusions

About one-tenth of donors are effectively used for transplantation purposes. Our findings highlight areas of success and challenges, providing a basis for future improvements in Colombia.

Comprehensive Surgical Audit of Live-Related Donor Nephrectomy: Procedural Parameters, Demographics, Health Assessments, Complications, and Postoperative Outcomes

BACKGROUND AND OBJECTIVES

End-stage renal disease (ESRD) rates are on the rise globally, including in India. However, the affordability of dialysis treatment remains a significant challenge for many, with costs varying across different regions. Although cost-effective, kidney transplantation faces challenges like a surgeon shortage, lack of infrastructure, and lack of logistic support. The study examines Indian laparoscopic nephrectomy outcomes and their benefits for donor recovery. It covers kidney donor procedural details, demographics, preoperative health evaluations, complications, and one-month follow-up.

METHODS

Ethical approval was obtained, and the study involved 102 cases at the Indira Gandhi Institute of Medical Science, Patna, Bihar, India, from 2019 to 2023. Detailed preoperative assessments, postoperative complications, and one-month follow-up analyses were conducted. Statistical analysis employed SPSS version 17 (IBM Corp., Armonk, NY).

RESULTS

The results revealed an average surgery time of 152.3 min, blood loss of 205 ± 42 ml, and a hospital stay of 4.6 ± 2.2 days. The study found a female predominance (80.39%), with a mean donor age of 35.9 ± 5.2 years. Preoperative assessments showed robust patient health, with glomerular filtration rate (GFR) exceeding the expected threshold and normal urea levels, creatinine, electrolytes, liver enzymes, bilirubin, albumin, and total protein. Post-nephrectomy complications were reported, with females experiencing more difficulties than males.

CONCLUSION

This study underscores the efficiency and safety of laparoscopic nephrectomy in the Indian context, providing valuable insights into donor demographics, preoperative health assessments, complications, and postoperative outcomes. The findings contribute to understanding laparoscopic nephrectomy outcomes and associated risk factors despite certain limitations.