A SYSTEMATIC REVIEW OF GENDER DISPARITY IN THE CONTINUUM OF CHRONIC KIDNEY DISEASE CARE

Chronic kidney disease (CKD) is a global health challenge, that affects vulnerable populations disproportionately. While ‘gender’ as a social construct has been identified to influence CKD care, its role as a determinant of inequity across the CKD care pathway has not been systematically examined.  This systematic review aimed to synthesize the global evidence on gender-based disparities across the continuum of CKD care.

The review was registered in PROSPERO (CRD420251091356) and conducted following PRISMA guidelines. Four databases (PubMed, Cochrane, HINARI, Embase) were searched (2000–2025). Two reviewers independently screened 1,022 articles and risk of bias was assessed using ROBINS-E. Studies examining biological differences, risk factor treatment, or trial inclusion disparities, those with secondary data, non-English publications and studies without availability of full texts were excluded. Data on gender disparities were extracted in relation to the following stages of the CKD care continuum: diagnosis, monitoring and medical management of CKD, initiation of dialysis inclusive of creation of vascular access and disparities related to various steps in the transplantation process including patient-provider communication, referral and evaluation, waitlisting and kidney transplantation surgery.  A meta-analysis was not conducted due to significant clinical and methodological heterogeneity. While we focused on gender as a social construct, we acknowledge the potential interplay with biological sex in relation to certain outcomes.

Twenty-seven studies were identified after abstract and full-text screening. Evidence from both high and low-middle income countries (LMICs) consistently demonstrated that women face disadvantages at each stage of CKD care. Women had lower odds of receiving a CKD diagnosis and nephrology referral, received less frequent monitoring of renal functions, and were less likely to be prescribed guideline-recommended medications. Among patients with end stage kidney disease, women were less prevalent on dialysis (38-41%) and women consistently initiated dialysis at a lower estimated glomerular filtration rate (8.1-10.1 versus 10.6 ml/min/1.73 m2 for men) in both high- and low-income settings.  Women were more likely to begin haemodialysis with temporary vascular catheters and were less likely to receive arteriovenous fistulas. Women also faced universal barriers during the transplant process with physicians being less likely to discuss transplantation as a treatment option, less likely to be referred for evaluation (37-42% of those referred), waitlisted (38-43%) and ultimately transplanted (20-40%).  These inequities were consistent across both high- and low-income settings but amplified in LMICs by unfavourable socioeconomic and cultural factors. Limited evidence on temporal variation reveals worsening gender-based disparity over time. 

This review provides evidence that gender-based disparities are universal in CKD care and systematically disadvantage women at each step in the care continuum. These findings highlight the need to integrate policies to ensure gender-equity in the management of CKD.