Meeting Report: First State of the Art Meeting on Gender Disparity in Kidney Transplantation in the Asia-Pacific

There had been numerous efforts worldwide to identify the issues pertaining to gender disparity in kidney transplantation.1 Globally, reports on inequity in access to transplantation have shown that adult women with kidney failure are less likely to receive dialysis than men.2,3 Among patients treated with dialysis, women are less likely to be listed for transplantation and once on the waiting list, they are also less likely to be transplanted.4 Despite technological advances and innovations in transplantation medicine and surgery, such as improved tissue typing and surgical techniques, such disparities are persistent, and the gaps are also widening.5 Recent research has also shown that the inequality in access to transplantation care observed between genders is further exacerbated by the economic consequences of ill health, particularly when women continue to fall down the social ladder because of their chronic diseases.6 To address the issue of global gender inequality in access to transplantation, the Asian Society of Transplantation in partnership with the Women in Transplantation (WIT) held 2 virtual meetings in January and February 2021 to discuss the pressing issues fueling gender inequality in transplantation in the Asia-Pacific and potential strategies to mitigate them. One of the key missions of WIT is to identify gaps and disparities in gender-specific health outcomes for both recipients and donors globally. Additionally, WIT is also driven to defend the welfare and justice of our transplant recipients and donors, with specific focus on addressing the issues of sex/gender disparity in disadvantaged settings. Fourteen speakers from 13 countries, including Australia, Bangladesh, Hong Kong, India, Indonesia, Japan, Malaysia, Mongolia, Myanmar, Pakistan, the Philippines, Singapore, and South Korea. Most of our speakers were clinician-scientists working in the field of transplantation and organ donation. At the time of the meeting, data from over 50 000 recipients and 20 000 donors were presented. Most of these data were collated from the participants’ national transplantation databases and from other representative sources such as center-level data over the past 3 decades. In this report, we summarize the key topics that stemmed from the information provided by the participants from each country and the future perspectives and strategies to tackle gender inequality that currently exists across both the living donation and transplantation sector in Asia-Pacific. Four common themes emerged from the meeting. First, men are at greater risk of developing kidney failure requiring dialysis and kidney transplantation. Second, the proportion of female living donors far exceeded male living kidney donors across all countries except for the Philippines, Hong Kong, and Pakistan. Of these, female spousal donors are disproportionately higher than men. Third, access to kidney transplantation is also not equal between sexes. Women are less likely to receive both living and donor kidney transplants compared with their male counterparts. More importantly, such observed disparities are not decreasing over time. Finally, despite having a higher proportion of female trainees in nephrology and transplantation, <10% of women currently hold leadership positions in the Asia-Pacific countries. All participants agreed that cultural-sensitive and country-specific implementable strategies are needed to close the gender disparity gaps. Overall, there was a female predominance of living donors (approximately 60% across most represented countries), and this pattern was sustained across all eras for Australia, Japan, Malaysia, and Korea (Figure 1). Such disparity was more apparent in Bangladesh and Indonesia, where the proportions of female live donors have increased over time and particularly in the last decade. Reasons for the observed disparity in living donations may be attributed to the overrepresentation of female spousal donors. In the Asia-Pacific, the proportion of wives donating to their husbands ranged from approximately 64%–90%, with a higher preponderance of ABO incompatible compared with ABO compatible living donor transplants (Figure 2). The Korean National Data reported that the over predominance of female spouse donors persisted from 2010 to 2020.FIGURE 1.: Proportions of female living donors in living donor kidney transplantation in Asia-Pacific. Data analysis was based on I: National, II: non-national representative, III: most recent (after 2018), national or non-national representative data.FIGURE 2.: Proportions of female spouse donors in living spousal donor kidney transplantation.Gender disparity was also evident access to transplantation. Fewer women received both deceased and living donor transplants than men. Across all participating countries, the proportion of female recipients of living donor kidney transplants varied between 18% in Bangladesh to approximately 40% in Australia, Hong Kong, and Korea and 52% in Myanmar. In Australia, the proportion of female living donor kidney transplantation has decreased over the last 2 decades, while the proportion of female living donor kidney transplantation has increased steadily in Hong Kong (Figure 3). Similar findings were also observed for deceased donor kidney transplantation. Except for Singapore, women in the Asia-Pacific were less likely to be listed for transplantation and once on the waiting list, they were also less likely to receive a transplant. Such disparities were more apparent among potential candidates with comorbidities. In Australia, obese women were less likely to be placed on the transplant waiting compared with their obese male counterparts.7FIGURE 3.: Proportions of female living kidney transplant recipients in Asia-Pacific. Data analysis was based on I: National, II: non-national representative, III: most recent (after 2018), national or non-national representative data.DISCUSSION Many factors have been proposed to explain the observed discrepancies between male and female donors and may include both biologic and social reasons. Men may be less likely to be accepted as donors because of the higher risk of preexisting comorbidities such as diabetes mellitus and hypertension. For spousal donation, wives may be sensitized to their husbands due to prior pregnancies and, therefore, men were precluded from donation to their spouses. However, the consensus among the participants was that social factors are the key contributors to the apparent excess of female donors in living transplantation in comparison to men. Here, we have summarized them into 4 categories: attitudinal, financial, patriarchism, and coercion. The decision to donate among women is highly influenced by their roles within the family and society. Traditionally, women are the sole caregivers within the family, and in many circumstances, not only have women donated their kidneys, but they have also continued to provide ongoing care and assistance to the recipients immediately after the surgery. At the societal level, there is a general expectation that women should be the “givers” rather than the takers. It is also important to note that similar trends are observed for siblings and offspring donations. In many countries of the Asia-Pacific, men are the only “bread-winner” in the household. The loss of income during the assessment and donation process, particularly for low-income families, is one of the major reasons why men are less likely to give. Deep-rooted patriarchy is also prevalent in this region. It is perhaps not at all uncommon to see undue coercion and pressure for women to donate. While there may be structural and economic pressures that have influenced a women’s choice to donate, many women who donated expressed immense personal gains and empowerment after donation. Women may feel a sense of relief because they no longer need to care for their husbands treated with long-term dialysis and some also considered donation as a form of protection for their children. The observed gender disparities in access to transplantation are a global issue and limited not only to the Asia-Pacific. In the United States, older women with comorbidities such as diabetes mellitus are much less likely to be listed for transplantation and receive a living donor kidney transplantation compared with older men with vascular disease.8 In France, the duration from first dialysis to listing is at least twice as long for women than men.9 Many contributing factors have been suggested and one of the commonly quoted reasons is the immunological dissimilarities between men and women, but this, however, does not explain the persistent discrepancies and the interactive differences in access to listing between sexes. The interplay between social, cultural, and societal factors (such as implicit provider biases, limited health disparity knowledge, and health education) is complex and requires a systematic approach by the global transplant community to actively address all modifiable factors. Future Perspectives and Conclusions Many strategies were discussed during the forum to close the gender gap. First, an equitable deceased donor allocation system to prioritize hard-to-match, highly sensitized individuals across the Asia-Pacific should be a key priority for the region. Second, a robust, transparent, and dynamic local paired kidney exchange program is needed to improve donation and transplantation rates. To do so, we will require a system change through the introduction of an independent multidisciplinary program that actively seek to promote and advocate for gender equality in organ donation. Regional and global educational workshops are needed to raise awareness on gender-specific issues within families and households. We also advocate for the provision of financial neutrality (modeled on National Living Donor Assistance in the United States) by the governments to remove economical and financial disincentives as barriers to living donation by men. We will involve key stakeholders and policy makers within the transplantation and donation sector in ongoing dialogue to set achievable short- and long-term goals to address the gender gap. We will develop a shared vision and explicit consensus on gender equality objectives in access to transplantation (living and deceased donor transplantation) for the individual countries within the region. We will consider a culturally sensitive living donor champion program that directly engages with our patient partners to ensure our goals and objectives are aligned with their priorities. Finally, we aim to establish a regional database containing elements related to gender selection bias during the life course and journey of a patient with kidney failure. Future research is also needed to evaluate and scrutinize the reasons for the observed gender inequality so that appropriate interventions could be implemented to close this gap.

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