Sex Differences in CKD-Associated Mortality From 1990 to 2019: Data From the Global Burden of Disease Study

Abstract

Rationale & objective: Previous studies have shown chronic kidney disease (CKD) mortality rates to be lower among females than males. We aimed to examine the extent to which sex differences vary over time, among countries, and with age, using Global Burden of Disease (GBD) Study data.

Study design: Observational epidemiological study.

Setting & participants: GBD Study, which used published literature, vital registration systems, kidney replacement therapy registries, and household surveys.

Exposures: Sex.

Outcomes: CKD-associated mortality rate (per 100,000 population).

Analytical approach: Changes in CKD mortality between 1990 and 2019 were compared between sexes, globally, and separately for the 50 most populous countries. For 2019 only, sex differences in age-standardized and age-specific mortality were compared between countries.

Results: There was no change in global age-standardized mortality for either sex between 1990 and 2019, with female mortality consistently 30% lower than male mortality. Percentage changes were less favorable among females than males in two-thirds of the 50 countries examined, with the greatest change disparities observed in Egypt, Thailand, and Malaysia. Although Mexico exhibited the greatest overall percentage increase, the increase was smaller in females (81% vs 138%). In 2019, female mortality varied between 47% lower and 60% higher than male mortality (in Angola and Egypt, respectively). In most countries, female mortality was lower across all age groups, with no narrowing of sex differences with age.

Limitations: We were not able to assess the sex differences according to CKD stage and we did not explore other disease metrics (eg, disability-adjusted life years).

Conclusions: Percentage changes in age-standardized CKD mortality have tended to be less favorable among females than males, with notable exceptions. Similarly, although female mortality is generally lower than male mortality, there are multiple examples of the opposite. Country-specific assessments of sex differences in CKD-associated outcomes are essential for equitable care.

Keywords: Chronic kidney disease; females; males; mortality; sex differences.

Graphical abstract

Figure 1

Global sex-specific all-age and age-standardized mortality rates (per 100,000 population) for chronic kidney disease in 1990, 2000, 2010, and 2019.

Figure 2

Changes in CKD age-standardized mortality rates (per 100,000 population) for females and males between 1990 and 2019 in 50 countries. The x-axis shows the difference in the male mortality rate between 1990 and 2019, and the y-axis shows the equivalent difference in female mortality rate. In countries that fall above the black diagonal line, changes were less favorable among females than males; the opposite is true for countries that fall below the line. Given that countries are unlikely to fall perfectly on the diagonal, guidelines with a y-intercept ±5 percentage points are also shown. Countries are represented by their ISO Alpha-2 codes: Afghanistan (AF), Algeria (DZ), Angola (AO), Argentina (AR), Bangladesh (BD), Brazil (BR), Canada (CA), China (CN), Colombia (CO), Democratic Republic of the Congo (CD), Egypt (EG), Ethiopia (ET), France (FR), Germany (DE), Ghana (GH), India (IN), Indonesia (ID), Iran (IR), Iraq (IQ), Italy (IT), Japan (JP), Kenya (KE), Malaysia (MY), Mexico (MX), Morocco (MA), Mozambique (MZ), Myanmar (MM), Nepal (NP), Nigeria (NG), Pakistan (PK), Peru (PE), Philippines (PH), Poland (PL), the Republic of Korea (KR), Russia (RU), Saudi Arabia (SA), South Africa (ZA), Spain (ES), Sudan (SD), Tanzania (TZ), Thailand (TH), Turkey (TR), Uganda (UG), Ukraine (UA), United Kingdom (GB), United States (US), Uzbekistan (UZ), Venezuela (VE), Vietnam (VN), and Yemen (YE). CKD, chronic kidney disease; SDI, sociodemographic index.

Figure 3

Sex-specific age-standardized mortality rates (per 100,000 population) in 2019 for chronic kidney disease in each of the 50 selected countries. Countries are ordered in descending order of total mortality rate.

Figure 4

Global sex-specific chronic kidney disease mortality rates (per 100,000 population) in 2019 plotted according to age group.

Figure 5

Female-to-male MRRs for chronic kidney disease across the 50 selected countries in 2019 according to age. The median and interquartile intervals for the MRR are shown by the solid lines inside the boxes. The mean is depicted by red dots. The dashed line indicates unity, where the MRR is equal to 1. MRR, mortality rate ratio.