title: Sex-specific differences in hemodialysis prevalence and practices and the male-to-female mortality rate: the Dialysis Outcomes and Practice Patterns Study (DOPPS).
abstract: BACKGROUND
  A comprehensive analysis of sex-specific differences in the characteristics, treatment, and outcomes of individuals with end-stage renal disease undergoing dialysis might reveal treatment inequalities and targets to improve sex-specific patient care. Here we describe hemodialysis prevalence and patient characteristics by sex, compare the adult male-to-female mortality rate with data from the general population, and evaluate sex interactions with mortality.
  
  
  RESULTS
  We assessed the Human Mortality Database and 206,374 patients receiving hemodialysis from 12 countries (Australia, Belgium, Canada, France, Germany, Italy, Japan, New Zealand, Spain, Sweden, the UK, and the US) participating in the international, prospective Dialysis Outcomes and Practice Patterns Study (DOPPS) between June 1996 and March 2012. Among 35,964 sampled DOPPS patients with full data collection, we studied patient characteristics (descriptively) and mortality (via Cox regression) by sex. In all age groups, more men than women were on hemodialysis (59% versus 41% overall), with large differences observed between countries. The average estimated glomerular filtration rate at hemodialysis initiation was higher in men than women. The male-to-female mortality rate ratio in the general population varied from 1.5 to 2.6 for age groups <75 y, but in hemodialysis patients was close to one. Compared to women, men were younger (mean = 61.9 ± standard deviation 14.6 versus 63.1 ± 14.5 y), were less frequently obese, were more frequently married and recipients of a kidney transplant, more frequently had coronary artery disease, and were less frequently depressed. Interaction analyses showed that the mortality risk associated with several comorbidities and hemodialysis catheter use was lower for men (hazard ratio [HR] = 1.11) than women (HR = 1.33, interaction p<0.001). This study is limited by its inability to establish causality for the observed sex-specific differences and does not provide information about patients not treated with dialysis or dying prior to a planned start of dialysis.
  
  
  CONCLUSIONS
  Women's survival advantage was markedly diminished in hemodialysis patients. The finding that fewer women than men were being treated with dialysis for end-stage renal disease merits detailed further study, as the large discrepancies in sex-specific hemodialysis prevalence by country and age group are likely explained by factors beyond biology. Modifiable variables, such as catheter use, showing significant sex interactions suggest interventional targeting. Please see later in the article for the Editors' Summary.
authors.affiliation: Clinical Division of Nephrology & Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
authors.forename: Manfred
authors.initials: M
authors.lastname: Hecking
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States of America.
authors.forename: Brian A
authors.initials: BA
authors.lastname: Bieber
authors.affiliation: Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Jean
authors.initials: J
authors.lastname: Ethier
authors.affiliation: Gender Medicine Unit, Clinical Division of Endocrinology & Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Kautzky-Willer
authors.affiliation: Clinical Division of Nephrology & Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
authors.forename: Gere
authors.initials: G
authors.lastname: Sunder-Plassmann
authors.affiliation: Clinical Division of Nephrology & Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
authors.forename: Marcus D
authors.initials: MD
authors.lastname: Säemann
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States of America.
authors.forename: Sylvia P B
authors.initials: SP
authors.lastname: Ramirez
authors.affiliation: Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, United States of America.
authors.forename: Brenda W
authors.initials: BW
authors.lastname: Gillespie
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States of America.
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Pisoni
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States of America.
authors.forename: Bruce M
authors.initials: BM
authors.lastname: Robinson
authors.affiliation: Arbor Research Collaborative for Health, Ann Arbor, Michigan, United States of America.
authors.forename: Friedrich K
authors.initials: FK
authors.lastname: Port
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011446:Prospective Studies; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012737:Sex Factors