Sex and Gender Differences in Patient Outcomes in Individuals Living with Chronic Kidney Disease
More than 48,000 Canadians live with kidney failure and require life-sustaining kidney replacement therapy, in the form of dialysis. The prevalence of dialysis continues to rise, increasing by 1.6% annually, with the majority of patients initiating in-centre hemodialysis (ICHD) compared to home-based dialysis (home hemodialysis [HD] and peritoneal dialysis [PD]). Although dialysis is essential for survival, patients experience poorer outcomes compared to the general population, including poor quality of life and increased risk of mortality and morbidity. Home-based dialysis offers potential benefits yet remains underutilized. Further, females living with chronic kidney disease receiving dialysis experience worse outcomes compared to males, including reduced quality of life and increased risk of mortality. However, it remains unclear if these health disparities are attributable to sex (biological) and/or gender (sociocultural) differences. Therefore, the objective of this thesis was to investigate sex and gender differences in individuals living with chronic kidney disease and important clinical outcomes. This work comprises of three studies. First, a mixed-methods study investigated how gender and gender-related factors influenced an individual’s likelihood of choosing home dialysis. From this work, we observed that although a majority of individuals are likely to choose home dialysis, gender factors may influence that choice, including marital status and support systems at home. Second, a prospective cohort study examined sex- and gender-related differences in HRQoL among individuals living with kidney failure treated with conventional (3x/week) compared to incremental (2x/week) HD. After 3 months, we found that females on conventional dialysis had improved physical health and females that had roles traditionally ascribed to women in Western societies had improved mental health on incremental HD while no differences were observed in males, irrespective of gender and HD type. Third, a systematic review and narrative synthesis explored sex differences between measures of HD adequacy and quality and clinical outcomes, including mortality. Although, there was significant variability in the reporting of HD adequacy and quality, we observed a trend toward lower all-cause mortality among females, with a greater benefit in females compared to males. Collectively, these studies highlight important sex and gender differences in individuals living with kidney failure that may negatively impact important health outcomes. This thesis provides a multifaceted analysis of how sex and gender play a role in dialysis modality choice, quality of life, and survival. These findings underscore the necessity to integrate both sex and gender considerations in dialysis decision-making and treatment planning to promote a more personalized approach to kidney care, further helping to reduce disparities in outcomes for individuals living with kidney disease.
chronic kidney disease, sex differences, gender differences, hemodialysis
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