Sex Differences in the Recognition, Monitoring, and Management of CKD in Health Care: An Observational Cohort Study
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Significance StatementIn this study of people with probable CKD accessing health care, we observed profound sex differences in detection, recognition, and monitoring that persisted over time: women were less likely to receive a CKD diagnosis, to visit a nephrologist, to have their creatinine and albuminuria measured, or to receive guideline-recommended therapies. Differences in comorbidity did not explain these discrepancies and were similar among high-risk groups, among patients with evidence-based indications for medications, and among patients with confirmed CKD at retesting. Efforts to improve and ensure equitable health care between the sexes could have important implications for justice and could reduce the burden of CKD.IntroductionReported sex differences in the etiology, population prevalence, progression rates, and health outcomes of people with CKD may be explained by differences in health care.MethodsWe evaluated sex as the variable of interest in a health care–based study of adults (n=227,847) with at least one outpatient eGFR<60 ml/min per 1.73 m2 measurement denoting probable CKD in Stockholm from 2009 to 2017. We calculated the odds ratios for diagnosis of CKD and provision of RASi and statins at inclusion, and hazard ratios for CKD diagnosis, visiting a nephrologist, or monitoring creatinine and albuminuria during follow-up.ResultsWe identified 227,847 subjects, of whom 126,289 were women (55%). At inclusion, women had lower odds of having received a diagnostic code for CKD and were less likely to have received RASi and statins, despite having guideline-recommended indications. In time-to-event analyses, women were less likely to have received a CKD diagnosis (HR, 0.43; 95% CI, 0.42 to 0.45) and visited a nephrologist (HR, 0.46; 95% CI, 0.43 to 0.48) regardless of disease severity, presence of albuminuria, or criteria for referral. Women were also less likely to undergo monitoring of creatinine or albuminuria, including those with diabetes or hypertension. These differences remained after adjustment for comorbidities, albuminuria, and highest educational achievement, and among subjects with confirmed CKD at retesting. Although in absolute terms all nephrology-care indicators gradually improved over time, the observed sex gap persisted.ConclusionsThere were profound sex differences in the detection, recognition, monitoring, referrals, and management of CKD. The disparity was also observed in people at high risk and among those who had guideline-recommended indications.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2022_10_11_JASN2022030373.mp3.
