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Equally Interchangeable? How Sex and Gender Affect Transplantation

Melk, Anette, MD, PhD1; Babitsch, Birgit, PhD, MPH2; Borchert-Mörlins, Bianca, MD1; Claas, Frans, PhD3; Dipchand, Anne I., MD4; Eifert, Sandra, MD5; Eiz-Vesper, Britta, PhD6; Epping, Jelena, PhD7; Falk, Christine S., PhD8; Foster, Bethany, MD9,10; Geyer, Siegfried, PhD7; Gjertson, David, PhD11; Greer, Mark, MD12; Haubitz, Marion, MD13; Lau, Ashley, MD14; Maecker-Kolhoff, Britta, MD15; Memaran, Nima, MD1; Messner, Hans A., MD, PhD16,†; Ostendorf, Karen1; Samuel, Undine, MD17; Schmidt, Bernhard M.W., MD18; Tullius, Stefan G., MD19; West, Lori, MD, PhD20; Wong, Germaine, PhD21,22; Zimmermann, Tanja, PhD23; Berenguer, Marina, MD24

doi: 10.1097/TP.0000000000002655

Organ transplantation as an option to overcome end-stage diseases is common in countries with advanced healthcare systems and is increasingly provided in emerging and developing countries. A review of the literature points to sex- and gender-based inequity in the field with differences reported at each step of the transplant process, including access to a transplantation waiting list, access to transplantation once waitlisted, as well as outcome after transplantation. In this review, we summarize the data regarding sex- and gender-based disparity in adult and pediatric kidney, liver, lung, heart, and hematopoietic stem cell transplantation and argue that there are not only biological but also psychological and socioeconomic issues that contribute to disparity in the outcome, as well as an inequitable access to transplantation for women and girls. Because the demand for organs has always exceeded the supply, the transplant community has long recognized the need to ensure equity and efficiency of the organ allocation system. In the spirit of equity and equality, the authors call for recognition of these inequities and the development of policies that have the potential to ensure that girls and women have equitable access to transplantation.

1 Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.

2 Human Sciences, New Public Health, University Osnabrück, Osnabrück, Germany.

3 Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands.

4 Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada.

5 Department for Cardiac Surgery, Ludwig-Maximilians-University, Munich, Germany.

6 Institute for Transfusion Medicine, Hannover Medical School, Hannover, Germany.

7 Department of Medical Sociology, Hannover Medical School, Hannover, Germany.

8 Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany.

9 Montreal Children’s Hospital, McGill University, Montreal, Canada.

10 Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada.

11 Division of Biostatistics, University of California, Los Angeles School of Public Health, Los Angeles, CA.

12 Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.

13 Department of Nephrology and Hypertension, Center for Internal Medicine, Klinikum Fulda, Fulda, Germany.

14 Department of Surgery, Duke University School of Medicine, Durham, NC.

15 Department of Pediatric Hematooncology, Hannover Medical School, Hannover, Germany.

16 Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.

17 Eurotransplant International Foundation, Leiden, The Netherlands.

18 Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.

19 Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.

20 Departments of Pediatrics, Surgery, Medical Microbiology/Immunology and Laboratory Medicine/Pathology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada.

21 Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia.

22 Sydney School of Public Health, University of Sydney, Sydney, Australia.

23 Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany.

24 Liver Transplantation & Hepatology Unit, Hospital Universitario La Fe, IIS La Fe, University of Valencia-CIBEReHD, Valencia, Spain.

Received 25 September 2018. Revision received 10 January 2019.

Accepted 23 January 2019.

† In memory of Dr. Hans August Messner (1941–2018), to whom this article is dedicated.

A.M., B.M.W.S., and M.B. participated in conception and design. A.M., B.B., C.F., S.G., and B.M.W.S. participated in acquisition of funding. A.M., B.B., F.C., A.I.D., S.E., B.E.V., J.E., B.F., S.G., D.G., M.G., A.L., M.H., B.M.K., N.M., H.A.M., K.O., U.S., B.M.W.S., S.G.T., L.W., G.W., T.Z., and M.B. participated in literature research. A.M., B.F., S.G., M.G., A.L., H.A.M., N.M., K.O., B.M.W.S., S.G.T., and M.B. participated in drafting the article. A.M., B.B., B.F., F.C., A.I.D., S.E., B.E.V., J.E., C.F., B.F., S.G., D.G., M.G., A.L., M.H., B.M.K., N.M., K.O., U.S., B.M.W.S., S.G.T., L.W., G.W., T.Z., and M.B. reviewed the article.

The authors declare no conflicts of interest.

B.B., C.F., S.G., A.M., and B.M.W.S. were supported by Ministry of Science and Culture of Lower Saxony within the program “Geschlecht-Macht-Wissen.”K.O. received support through the KlinStrucMed program at Hannover Medical School, funded by Else-Kröner-Fresenius foundation. CIBEReHD is partially funded by the Instituto de Salud Carlos III.

Correspondence: Anette Melk, MD PhD, Children’s Hospital, Hannover Medical School; Carl-Neuberg-Str. 1, 30625 Hannover, Germany. (

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