Sex Differences in Mortality and Receipt of Kidney Replacement Therapy Among Adults With Stage 5 Chronic Kidney Disease
Bibliographic record
Abstract
Importance: Female individuals typically outlive male individuals in the general population. Whether this survival advantage persists among adults with stage 5 chronic kidney disease (CKD) is unknown. Objective: To examine sex differences in mortality and treatment with kidney replacement therapy (KRT; including dialysis and transplant) among adults with incident stage 5 CKD. Design, Setting, and Participants: This population-based cohort study used linked administrative and kidney care program data from Alberta, Canada. Adults 18 years and older with incident non-KRT-dependent stage 5 CKD were identified between April 2005 and March 2019 and observed from study entry until death, out-migration, or March 2021. Data were analyzed from January to August 2025. Main Outcomes and Measures: Sex-specific, age-stratified standardized mortality ratios were calculated using general population mortality data. Five-year probabilities of all-cause death, receipt of maintenance dialysis, and kidney transplant were estimated in incident stage 5 CKD cases using multistate models, stratified by age and presence of diabetes or cardiovascular disease. Results: Among 7506 cohort members, 4121 (54.9%) were male (median [IQR] age, 70 [58-80] years), and 3385 (45.1%) were female (median [IQR] age, 74 [61-83] years). The median (IQR) follow-up was 7.9 (4.7-11.5) years. Compared with the general population, female individuals experienced greater excess mortality than male individuals, particularly at younger ages (eg, among adults younger than 55 years: standardized mortality ratio, 40.9 [95% CI, 34.6-47.3] in female individuals vs 15.9 [95% CI, 13.5-18.2] in male individuals); this difference narrowed with increasing age. Within the stage 5 CKD cohort, 5-year all-cause mortality risks were higher in younger female individuals than male individuals (younger than 55 years: 20.7% vs 14.6%) and similar between sexes at older ages. Irrespective of comorbidity, female individuals younger than 65 years were substantially less likely to receive a kidney transplant, and female individuals 65 years and older were less likely to receive dialysis or a transplant. Conclusions and Relevance: In this cohort study using data from a universal health care system, across all ages, the female survival advantage observed in the general population was absent or even reversed after developing stage 5 CKD. Fewer female individuals transitioned to KRT treatment, independent of their comorbidities. Younger female individuals experienced the greatest survival disadvantage and were less likely to receive a transplant. These findings suggest that differences in treatment decision-making or inequities in access to KRT may contribute to poorer outcomes in female individuals, especially at younger ages. Further investigations are warranted to understand the potential underlying structural, social, and biological mechanisms.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.002 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".