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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2022  |  Volume : 33  |  Issue : 1  |  Page : 168-171
Is There Gender Discrimination in Living-Donor Kidney Transplantation?

Department of Nephrology, Dialysis and Renal Transplantation, Mohammed VI University Hospital, Oujda, Morocco

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Date of Web Publication16-Jan-2023


Kidney transplantation is the ideal treatment for patients with end-stage kidney disease as it provides better survival and quality of life. The best form is living donor kidney transplantation. Numerous studies documented significant gender inequality when it comes to receiving or donating a kidney transplant among women. This article will summarize the present knowledge of gender-related kidney transplantation and discuss the potential causes for the observed disparities and their consequences.

How to cite this article:
Barmoussa O, Bentata Y, Haddiya I. Is There Gender Discrimination in Living-Donor Kidney Transplantation?. Saudi J Kidney Dis Transpl 2022;33:168-71

How to cite this URL:
Barmoussa O, Bentata Y, Haddiya I. Is There Gender Discrimination in Living-Donor Kidney Transplantation?. Saudi J Kidney Dis Transpl [serial online] 2022 [cited 2023 Jan 29];33:168-71. Available from: https://www.sjkdt.org/text.asp?2022/33/1/168/367810

   Introduction Top

Kidney transplantation is the ideal treatment for patients with end-stage kidney disease (ESKD) as it provides better survival and quality of life. The best form is living donor kidney transplantation, with a superior outcome than deceased kidney donors.[1] Numerous studies documented significant gender inequality when it comes to receiving or donating a kidney transplant.[2],[3],[4] In fact, females receive fewer kidney transplants from living donors than men, while they are more likely to donate.

Possible explanations and potential factors that can lead to this disparity were discussed in many studies.[2],[3] The most important ones are the economic factors such as the higher income of men that may encourage females to volunteer more, greater female sense of responsibility, etc. Furthermore, men may be excluded as donors as they are more likely to develop hypertension and ischemic heart disease than their female counterparts.[5]

This article will summarize the present knowledge of gender-related kidney transplantation and discuss the potential causes for the observed disparities and their consequences.

   Data from All over the World Top

There is a paucity of data in this regard from developing countries; almost all available data come from developed countries.

In most developing countries, transplantation activity is limited and faces several constraints and challenges. Live kidney donation is the pillar of renal transplantation in these countries. Almost all kidney transplants are performed with a related living donor (first or second degree) due to a lack of cadaveric organ procurement, mainly because of religious and cultural convictions.[6]

Data regarding kidney transplants performed in Morocco, for instance, showed that between June 1998 and December 2008 in Ibn Sina University Hospital center, 64.1% of the recipients were men, and women only accounted for 35.8% of the patients who received a kidney transplant. On the other hand, donors were women in 70% of cases, namely mothers (41.7%) or sisters (28.3%).[4]

Live kidney donors account for approximately half of all kidney transplantations performed in the US.[3] In France, the rate is 16% of transplants compared to 43% in Denmark and 53% in the Netherlands.[7] Regarding access to renal transplantation, the rates are lower for women than men in European countries and the US and very low outside of these countries: 31% in Korea, 26% in Egypt, 23% in Turkey, 22% in Pakistan, and 19.7% in Syria.[8]

In India, one report states that only 7% of kidney recipients are females, a country where living-related donors constitute the majority of renal transplantations, the females constitute approximately 55% of the donors but only 6% of the recipients.[3] Another study from the same country indicates that 88.9% of the recipients of related and unrelated kidney donors were males, and only 11.1% of the recipients were females. The most significant gender disparity was observed within the spousal group, where wives donated 90.7% of their kidneys to their husbands, but husbands donated only 9.3% of the kidneys to their wives.[9]

An interesting study that included 52,690 living donors was published in the American Society of Nephrology Journal by Gill et al[2] confirmed that the association between donor’s gender and socioeconomic status and living kidney donation rates is well and truly present. After adjustment for age, race, median household income, rate of ESKD, and in the rural-urban commuting area, women still had a 44% higher incidence of donation compared to men, with donation rates that remained stable from 2004 to 2015 in women but declined in men, further increasing gender inequality. For both men and women, donation rates were more stable in the higher-income population than in the lower-income group.

There is clearly an inequality in access to kidney transplantation, disadvantaging women, found in most of the published papers, especially those from countries with strict laws that prohibit getting financial rewards for a kidney donation. However, in Iran, the only country in the world where people can legally sell their kidneys, studies demonstrated that more men than women volunteer for kidney donation. In a study performed at Hashemi Nejad Kidney Hospital, Tehran,[8] 1500 renal transplantations were performed between April 1986 and May 2002. The recipients were male in 63.1%, and 36.9% were female, which is consistent with the previously reported results, but of the 1500 investigated kidney donors, 1170 (78%) were male, and 330 (22%) were female. This increase in the males to females proportion for kidney donation is due to adopting a controlled living-unrelated renal donor (LURD) transplantation program in Iran since 1988. In this program, each LURD receives a donor award from the government, gets free health insurance, and a rewarding gift from the recipient or a charity. Because of these financial incentives, many males choose to become LURDs. However, it is illegal for the medical and surgical teams involved or any “middleman” to receive payment.[10] In the rest of the world, kidney donors are not paid, at least not legally.

Since the establishment of this system in Iran, the number of transplants had almost doubled; nearly four-fifths were from living unrelated sources. This made some authors wonder whether the “Iranian model” of payment for LURD could be useful in other countries to solve the issue of kidney donor shortage.[10]

   The Moroccan Experience Top

In Morocco, we have seven approved organ transplant centers, three in Rabat (Ibn Sina University Hospital, Mohamed V Military Hospital, Cheikh Zaid Hospital), Ibn Rochd University Hospital in Casablanca, Mohammed VI University Hospital in Marrakech, Hassan II University Hospital in Fez, and Mohammed VI University Hospital of Oujda.

In these centers, 588 kidney transplantations were performed in a period of 34 years (from 1986 to 2019). The recipients were mainly men with a percentage of 63.9% and a gender ratio of 1.8. Their mean age was 33.8 ± 12.4 years (4−67).

Five hundred and twenty-two of the kidneys were from a living donor and 66 from a deceased one. The mean age of donors was 43 ± 11.4 years (18−71).

Among the 42.45% who specified the gender of the donors, 30% were women with a female predominance of 70.7%.[11]

   Potential Factors Leading to Gender Inequality in Living Donor Kidney Transplantation Top

The issue of gender imbalance in living organ donation is multifactorial. Most studies showed that women score higher on most measures of values associated with helping others and have higher voluntarism rates.[12] They also showed that both women and men expect women to be more altruistic than men.[13] Hence, the higher rate of female donors can be explained by society’s expectations of women to be more generous and caregiving.

It has also been suggested that men might be excluded more often from kidney donation because of a greater incidence of comorbidities like hypertension and heart diseases[3],[5] and a higher rate of ESKD,[14] so it is only logical that the unaffected family members are more likely to be women.

The most considerable differences in donation between women and men were mainly observed in spousal donations.[2] This could be explained by the fact that many men are the primary household income earner and are likely to earn higher wages than women. This may cause inequality in living donors since most medical insurances do not cover the expenses, so the fear of work interruption with no indemnities or, worst, losing a job with the medical insurance can be a problem for working people, especially since living donors will be needing a rigorous medical follow-up after the donation. On the other hand, some females probably have health insurance as dependents. Consequently, the threat of job loss may not necessarily affect their ability to access health care in the future.[2]

This analysis highlights the importance of having laws that give employees the right to medical leave if they choose to be donors, and even more importantly, the assurance that they will have no problems as living donors in getting insurance policies or bank loans. Donation must be financially neutral for living donors. The development of these laws will undoubtedly help increase living donations, particularly from men.

The fear of ESKD is another issue in living donation; it is essential to understand that other than the potential role of APOL-1 gene risk variants in African descent individuals,[15] the basis for an increased risk of kidney failure in living donors is not proved by studies. On the contrary, studies show that the risk of ESKD in kidney donors is equal to the general population,[16] but the idea of having just one kidney might be scary for some people, particularly those who have seen a family member go through ESKD complications and dialysis.

Religious and cultural concerns are fundamental reasons for people to refuse any organ donation, both in developed and developing countries. As many people from various cultures and religions believe that donation is prohibited because it alters the human body’s integrity and is therefore forbidden,[17] but they forget that altruism is also an important principle of all creeds and saving a life is the greatest gift of all. As Barak Obama pointed out in one of his speeches: “We should never forget that God granted us the power to reason so that we would do His work here on Earth - so that we would use science to cure disease, and heal the sick, and save lives.”[18]

   Conclusion Top

Living organ donors are real-life heroes; they choose to go through a surgical operation with the risk of further medical complications and no personal benefit. Women should be proud to be the ones that donate the most. However, health-care systems all over the world must ensure that there is no gender discrimination in the process of getting a kidney transplant. There is also an urgent need for laws that ensure that living donors will get no consequences after their heroic acts. Nonetheless, the reasons for men’s living donation decline require further studies.

Conflict of interest: None declared.

   References Top

Terasaki PI, Cecka JM, Gjertson DW, Takemoto S. High survival rates of kidney transplants from spousal and living unrelated donors. N Engl J Med 1995;333:333-6.  Back to cited text no. 1
Gill J, Joffres Y, Rose C, et al. The change in living kidney donation in women and men in the United States (2005-2015): A population-based analysis. J Am Soc Nephrol 2018;29: 1301-8.  Back to cited text no. 2
Khalifeh N, Hörl WH. Gender and living donor kidney transplantation. Wien Med Wochenschr 2011;161:124-7.  Back to cited text no. 3
Haddiya I, Radoui A, Benamar L, et al. Ten years of renal transplantation in a Moroccan hospital: Results and constraints. Transplant Proc 2012;44:2976-81.  Back to cited text no. 4
The EUGenMed Cardiovascular Clinical Study Group, Regitz-Zagrosek V, et al. Gender in cardiovascular diseases: Impact on clinical manifestations, management, and outcomes. Eur Heart J 2016;37:24-34.  Back to cited text no. 5
Flayou K, Kouam N, Miara H, et al. Attitudes toward organ donation among personnel from the University Hospital of Rabat. Saudi J Kidney Dis Transpl 2016;27:758-61.  Back to cited text no. 6
[PUBMED]  [Full text]  
Châtelet V, Gatault P, Hazzan M, et al. Caractéristiques des centres de greffe associées à la greffe rénale avec donneur vivant en France: Une analyse hiérarchique avec un modèlemultiniveau. Néphrologie Thérapeutique 2018;14:275-6.  Back to cited text no. 7
Ghods AJ, Nasrollahzadeh D. Gender disparity in a live donor renal transplantation program: Assessing from cultural perspectives. Transplant Proc 2003;35:2559-60.  Back to cited text no. 8
Bal MM, Saikia B. Gender bias in renal transplantation: Are women alone donating kidneys in India? Transplant Proc 2007;39: 2961-3.  Back to cited text no. 9
Major RW. Paying kidney donors: Time to follow Iran? Mcgill J Med 2008;11:67-9.  Back to cited text no. 10
Bouattar T. Renal Transplantation in Morocco: National Survey, 1986-2019. Webinar "Renal Transplantation in Morocco"; July 07, 2020.  Back to cited text no. 11
Tinghög G, Andersson D, Bonn C, et al. Intuition and moral decision-making − The effect of time pressure and cognitive load on moral judgment and altruistic behavior. PLoS One 2016;11:e0164012.  Back to cited text no. 12
Brañas-Garza P, Capraro V, Rascon-Ramirez E. Gender differences in altruism on Mechanical Turk: Expectations and actual behaviour. Econ Lett 2018;170:19-23.  Back to cited text no. 13
IsekiK. Gender differences in chronic kidney disease. Kidney Int 2008;74:415-7.  Back to cited text no. 14
Foster MC, Coresh J, Fornage M, et al. APOL1 variants associate with increased risk of CKD among African Americans. J Am Soc Nephrol 2013;24:1484-91.  Back to cited text no. 15
Fehrman-Ekholm I, Nordén G, Lennerling A, et al. Incidence of end-stage renal disease among live kidney donors. Transplantation 2006;82:1646-8.  Back to cited text no. 16
Oliver M, Woywodt A, Ahmed A, Saif I. Organ donation, transplantation and religion. Nephrol Dial Transplant 2011;26:437-44.  Back to cited text no. 17
Obama B. Healthcare & Health Issues. December 01, 2006 Race Against Time. 2006 Global Summit on AIDS and the Church. Saddleback Church Campus; 2006.  Back to cited text no. 18

Correspondence Address:
Ouidad Barmoussa
Department of Nephrology, Dialysis and Renal Transplantation, Mohammed VI University Hospital, Oujda
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.367810

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