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The prevalence of chronic kidney disease (CKD) is higher in women than in men, yet lower rates of women receive kidney replacement therapy (KRT) worldwide. Whilst an explanation could be a slower progression of the disease, studies in this area suggest that this may be due to women having lower access to KRT, reflecting broader healthcare disparities. Patient-perceived barriers represent the challenges patients encounter accessing healthcare services or treatments. Globally, gender inequality in CKD persists, with clinicians and researchers exploring numerous hypotheses to understand this phenomenon.
Objective: To investigate the barriers to women’s access to kidney care.
We conducted a literature review from three distinct perspectives: published data indicating a gender disparity in KRT; the nephrologist perspective on barriers to access kidney care, and the perspectives of women with CKD.
Published data perspective: in 2021, 36% of the incident KRT patients were female in Europe, 287 pmp versus 461 pmp male in United States, and 42% in Latin America. As countries with higher income present a higher prevalence of KRT, it’s been reported a possible association between gender inequality and double burden of disease in women from low- and middle-income countries. The prevalence rate ratio male: female has variations across CKD stages, being < 1 in early stages, reversing to > 1 in KRT. Even though there is still a possibility of an over estimation of glomerular filtration rate in women, other explanations could be women’s higher attendance rate in healthcare services or a slower progression to end stage disease. However, at the same level of kidney function as men, women are also at higher risk of progressing to end-stage disease when taking their cardiovascular risk into account. Also, awareness levels of previous kidney disease in women were reported much lower than in men (2.9% vs. 17.9% respectively), which may contribute to later initiation of KRT. In relation to kidney transplant, while more men are present on waiting lists, women are more likely to be kidney donors. While an explanation is a reduced access to decease donor transplantations due to elevated levels of pre-existing antibodies, others suggest that it could be attributed to a lower educational level and financial resources. Nephrologist’s perspective: the results of two survey-based studies indicated knowledge gaps as well as lack of recognition of patient gender disparities. However, other survey-based studies demonstrated that most nephrologists perceived women as dedicated to their role in the family and that this often led to prioritize their family over their own health. They mentioned that women considered the potential impact on their family and sought treatments which retained their self-reliance, avoiding treatments which could burden their family. Additionally, the ISN launched an “Expert Series” that addresses the ethical aspects of kidney care for women. Various international meetings discussed this issue, and several gender-related committees were established. Patient’s perspective: Through our comprehensive search of the literature on this topic, we identified one abstract which directly addressed the barriers to women’s access to CKD treatment from a patient’s perspective. Many studies address the patient’s perspective but not differentiating by sex.
The literature identified in this study highlights a multitude of factors which can contribute to the gender disparity in access to treatment in women with CKD. These disparities have often been explained based on physiological factors. However, there is a noticeable absence of research on women with CKD’s perceptions of this topic. This research should seek to highlight patient’s experiences within this area, focusing on patient voice and gaining insight on how barriers can be mitigated or overcome to improve patients access to essential treatments.