RATIONALE & OBJECTIVE: Women with kidney failure have reduced access to kidney transplantation compared to men. We examined trends in sex inequities in access to transplantation over time. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 2.3 million adults identified within the United States Renal Data System, aged 18-79 years, who initiated kidney replacement therapy (KRT) between 1997 and 2020. EXPOSURES: Era of KRT (1997-2000, 2002-2004, 2005-2008, 2009-2012, 2013-2016, or 2017-2020), Sex (male or female). OUTCOMES: Placement onto the kidney transplant waitlist or LDKT among all individuals initiating KRT, and DDKT among patients on the waitlist. ANALYTICAL APPROACH: Multivariable cause-specific hazard models to analyze the association between sex and placement onto the waitlist, LDKT, and DDKT, by era, overall, and by categories of age, race, and cause of kidney failure. RESULTS: Sex inequities in waitlisting became less pronounced over time. During 1997-2000 the adjusted hazard ratio comparing men to women was 0.81
95%CI: [0.79-0.83]) and by 2017-2020, narrowed to 0.86 [0.85-0.87]). For the outcome of LDKT, during 1997-2000, the adjusted hazard ratio comparing men to women was (0.89 [0.85-0.93]) and by 2017-2020, widened to 0.79 [0.76-0.82]). For the outcome of DDKT, during 1997-2000, the adjusted hazard ratio comparing men to women was (0.92 [0.89-0.95]) and by 2017-2020, widened to (1.16 [1.14-1.19]). Sex inequities in waitlisting and LDKT were greatest in women (vs. men) with diabetes (27% and 37%, respectively in 2017-2020) and older adults 60-79 years (24% and 34%, respectively in 2017-2020), but broadly similar across race groups. LIMITATIONS: Residual confounding
unknown true medical eligibility for transplant. CONCLUSIONS: Since 1997, sex inequities in waitlisting have improved but remain significant, especially for women who are older, and with diabetes-attributed kidney failure. Worsening sex inequities in LDKT among women and DDKT among waitlisted men, warrant further study.