Aims: We sought to determine if there are sex-based disparities in access to the deceased donor waitlist and/or transplantation, and how intersectional disadvantages such as minority ethnicity, low socio-economic position, cause of kidney failure, and high co-morbidity burden may interact with such disparities, in contemporary Australia.
Methods: A cohort study using the ANZDATA registry (2006-2021) to explore the associations between sex and intersectional disadvantage and  outcomes including waitlisting, deceased donor transplantation, and death. Cox proportional hazards models, two-way interaction models and competing risk analysis adjusted for baseline characteristics were used.
Results: 41,227 patients commenced dialysis during the study period, of which 15,454 (38%) were female, and were followed for 122,400 person-years. In our fully adjusted model, females were 19% less likely to be waitlisted (Hazard Ratio HR]0.81; 95%CI:0.77-0.84), than their male peers. The sex-based disparity in transplant waitlisting was larger for females with intersectional disadvantage including older age (females >45yrs HR 0.78;95%CI:0.74-0.83 compared to their male peers),ethnic minorities (eg. female Aboriginal and Torres Strait Islander HR 0.57;95%CI:0.48-0.68, female Asian HR 0.76;95%CI:0.69-0.84), low socio-economic position (HR 0.76; 95%CI: 0.69-0.83), diabetic kidney disease as the cause of kidney failure (HR 0.63;95%CI:0.57-0.69), and having ≥3 co-morbidities (HR 0.69;95%CI:0.57-0.84). There was no significant difference in deceased transplantation rates once waitlisted, or death on the waitlist for any groups.
Conclusions: Females have significantly less access to kidney transplant waitlisting than their male peers, and this sex-based disparity is amplified for females with intersectional disadvantage. Once waitlisted, there are no sex-based disparities in rates of deceased donor transplantation or death.