Sex Differences in the Recognition, Monitoring, and Management of CKD in Health Care: An Observational Cohort Study

Abstract

Introduction: Reported sex differences in the etiology, population prevalence, progression rates, and health outcomes of people with CKD may be explained by differences in health care.

Methods: We 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.

Results: We 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.

Conclusions: There 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.

Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2022_10_11_JASN2022030373.mp3.

Keywords: chronic kidney disease; epidemiology and outcomes; sex difference.

Graphical abstract

Figure 1.

Years 2009–2017 time trends in CKD care indicators among persons with first-ever eGFR<60 ml/min per 1.73 m² by sex, using men in 2009 as reference. Although in general indicators of CKD care have improved over time, women with CKD have been persistently less likely to receive the same degree of recognition, referral to kidney specialist and monitoring of kidney function over time than men. Time trends in the risk of receiving (A) a diagnosis of CKD, (B) visiting a nephrologist, (C) remeasurement of creatinine, and (D) measurement of albuminuria in the next 18 months using men in 2009 as reference, by sex and year of inclusion, and at first occurrence of an eGFR measurement <60 ml/min per 1.73 m² in the Stockholm region from 2009 to 2017. Hazard ratios are presented in Supplemental Table 5.