Abstract: Kidney transplant is the best kidney replacement treatment for end-stage kidney disease. The first step in moving toward kidney transplantation is referral to a transplant center for transplant evaluation. Education of dialysis staff and health-care providers may help increase referrals for evaluation. Patient education has been shown to enhance patient completion of the evaluation process. Patients have difficulty asking others to donate a kidney, but this process can be improved with home and community education. Living donors are more likely to be women than men, especially spousal donors. Deceased donors are more likely to be males younger than 35 years of age. There is a slight decrease in the rate of transplantation of women as compared with men, although not statistically significant. Pretransplant development of anti-human leukocyte antigen antibodies is more common amongst women and can be a barrier to successful transplantation and may prolong the waiting time for transplant. The long-term management of cardiovascular risk factors, osteoporosis, and age-appropriate cancer screening need to be addressed with posttransplant recipients. Women have an overall increased patient and graft survival as compared with men after transplant. Kidney transplant is the best kidney replacement treatment for end-stage kidney disease. The first step in moving toward kidney transplantation is referral to a transplant center for transplant evaluation. Education of dialysis staff and health-care providers may help increase referrals for evaluation. Patient education has been shown to enhance patient completion of the evaluation process. Patients have difficulty asking others to donate a kidney, but this process can be improved with home and community education. Living donors are more likely to be women than men, especially spousal donors. Deceased donors are more likely to be males younger than 35 years of age. There is a slight decrease in the rate of transplantation of women as compared with men, although not statistically significant. Pretransplant development of anti-human leukocyte antigen antibodies is more common amongst women and can be a barrier to successful transplantation and may prolong the waiting time for transplant. The long-term management of cardiovascular risk factors, osteoporosis, and age-appropriate cancer screening need to be addressed with posttransplant recipients. Women have an overall increased patient and graft survival as compared with men after transplant. Clinical Summary•Education of dialysis staff may help increase referral of patients for transplant evaluation.•There are gender and ethnicity differences in living kidney donation.•Cervical cancer rates are increased 15 fold in renal transplant recipients.•Fracture risk is increased in women post-transplant, especially those over age 65 years.•Generally women have a longer patient and graft survival than men. •Education of dialysis staff may help increase referral of patients for transplant evaluation.•There are gender and ethnicity differences in living kidney donation.•Cervical cancer rates are increased 15 fold in renal transplant recipients.•Fracture risk is increased in women post-transplant, especially those over age 65 years.•Generally women have a longer patient and graft survival than men. Kidney transplantation is considered to be the best option for renal replacement therapy for treatment of ESRD.1Wolfe R.A. Ashby V.B. Milford E.L. et al.Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.N Engl J Med. 1999; 341: 1725-1730Crossref PubMed Scopus (3995) Google Scholar Kidney transplantation is the only form of renal replacement therapy that actually replaces all aspects of kidney function. Patient survival after transplant is superior to survival on dialysis, although this is somewhat skewed by the fact that those candidates who are not well enough to be listed for transplantation remain on dialysis. However, comparisons of transplant recipients to those actively wait-listed for transplant, and therefore considered a candidate for transplant, continue to show a survival advantage for transplant recipients.1Wolfe R.A. Ashby V.B. Milford E.L. et al.Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant.N Engl J Med. 1999; 341: 1725-1730Crossref PubMed Scopus (3995) Google Scholar For one to be listed for kidney transplant, a referral must be made to a transplant center for a pretransplant evaluation. The intent of the evaluation process is to determine whether it is in the best interest of the patient to pursue kidney transplantation. The evaluation process typically involves a medical review and examination, an assessment by a social worker, and often a conversation with a financial coordinator. Underlying comorbid conditions such as active ischemic cardiac disease, peripheral vascular disease, active infection, current malignancy, or morbid obesity are factors that may render an individual not a candidate for transplantation. Earlier studies have documented discrepancies in referral rates of men vs women for transplantation.2Bloembergen W. Mauger E. Wolfe R. Port F.K. Association of gender and access to cadaveric renal transplantation.Am J Kidney Dis. 1997; 30: 733-738Abstract Full Text PDF PubMed Scopus (90) Google Scholar Women were referred for transplantation 25% less than men. A more recent study addressed rates of access to deceased donor transplantation in the United States.3Wolfe R.A. Ashby V.B. Milford E.L. et al.Differences in access to cadaveric renal transplantation in the United States.Am J Kidney Dis. 2000; 36: 1025-1033Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar Using the United States Renal Data System from 1991 to 1996, data were queried to evaluate factors influencing likelihood of receiving a deceased donor transplant. Women accounted for 45.6% of the population at onset of ESRD, 39.5% of those at wait-listing for transplantation, and 37.2% of those receiving a deceased-donor kidney transplant. In this large study, there was no statistically significant difference between men and women being wait-listed for transplant before the onset of ESRD requiring dialysis, but the likelihood of being wait-listed for transplant after initiation of dialysis was slightly less for women than for men by 16%, although this was not statistically significant. Why the proportion of women referred was less than men is not clear. Speculations have included less interest in pursuing transplant on the part of women, less availability of family support after transplantation, and concerns that the option for transplantation has not been brought up by the medical community. There are also patient barriers to proceeding with evaluation4Kazley A.S. Simpson K.N. Chavin K.D. Baliga P. Barriers facing patients referred for kidney transplant cause loss to follow-up.Kidney Int. 2012; 82: 1018-1023Crossref PubMed Scopus (46) Google Scholar that include the patients perception that they have too many medical problems and would not pass the medical tests, fear of pursuing and undergoing transplant, concerns that they cannot afford the transplant medications, and acceptance by the patient that dialysis is not so bad. Because the initial step toward transplant is having a referral to a transplant center, education of the dialysis staff, who often make the referral, is critical,5Boulware L.E. Hill-Briggs F. Kraus E.S. et al.Effectiveness of educational and social worker interventions to activate patients' discussion and pursuit of preemptive living donor kidney transplantation: a randomized controlled trial.Am J Kidney Dis. 2013; 61: 476-486Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar as is focused education of the patients regarding the option for transplant.6Patzer R.E. Perryman J.P. Pastan S. et al.Impact of a patient education program on disparities in kidney transplant evaluation.Clin J Am Soc Nephrol. 2012; 7: 648-655Crossref PubMed Scopus (59) Google Scholar, 7Sullivan C. Leon J.B. Sayre S.S. et al.Impact of navigators on completion of steps in the kidney transplant process: a randomized, controlled trial.Clin J Am Soc Nephrol. 2012; 7: 1639-1645Crossref PubMed Scopus (116) Google Scholar Physicians also need to be educated about criteria of their referral centers for listing because there may be misconceptions about patient eligibility. Completion of the evaluation process is another common obstacle to proceeding with transplant and can be enhanced by patient education. Geographic barriers to transplantation exist,8Mathur A.K. Ashby V.B. Sands R.L. Wolfe R.A. Geographic variation in end-stage renal disease incidence and access to deceased donor kidney transplantation.Am J Transplant. 2010; 10: 1069-1080Crossref PubMed Scopus (91) Google Scholar with areas experiencing a high rate of ESRD having a lower rate of access to transplantation. There are clearly racial disparities with respect to geographic barriers, although no evidence of a gender bias exists. There are over 96,000 patients listed for kidney transplantation with United Network Organ Sharing as of June 2013 (optn.transplant.hrsa.org). Listing criteria for transplantation vary somewhat between transplant centers, but they are generally similar. In general, patients need to be healthy enough to undergo the surgery for transplantation. The greatest impediment to being considered healthy enough to undergo surgery is underlying cardiovascular disease. Another major medical exclusion to transplantation is the presence of malignancy because exposure to immunosuppression may result in progression of malignancy because of impaired immune surveillance. Obesity can be an impediment to listing for transplantation, although the body mass index that is acceptable varies amongst centers from 30 to 40 kg/m2. A history of nonadherence is also a barrier to listing for transplantation and may include ongoing tobacco, alcohol, or recreational drug use or nonadherence to prescribed medical orders such as may be evidenced by missed dialysis runs, cutting dialysis short, or poor compliance with dietary restrictions. When facing transplant, the first decision point facing a recipient is whether a living donor is available. Living-donor transplants are a better option for recipients when possible. Patient and kidney allograft survival are typically better with a living donor, and surgery can be scheduled at a convenient time. One of the greatest barriers to a receiving a living-donor transplant is difficulty in asking others to donate a kidney. Patients are often concerned that family and friends will be angry with them for asking, they feel they will be bothering their family members, or they have concerns that they will be jeopardizing the health of others by asking for them to donate a kidney. Patients frequently have had a living-donor offer, but they decline this option because of the above concerns.9de Groot I.B. Schipper K. van Dijk S. et al.Decision making around living and deceased donor kidney transplantation: a qualitative study exploring the importance of expected relationship changes.BMC Nephrol. 2012; 13: 1-12PubMed Google Scholar Women are better at asking others to donate to a loved one as opposed to asking someone to donate a kidney on their own behalf. The best success in locating a living donor typically comes when there is an "advocate" for the recipient. This eases the discomfort of the recipient with directly asking others to give them a kidney. An improvement in transplant rates with a live donor, especially amongst African Americans, has been achieved through home-based donor education sessions.10Rodrigue J.R. Cornell D.L. Lin J.K. Kaplan B. Howard R.J. Increasing live donor kidney transplantation: a randomized controlled trial of a home-based educational intervention.Am J Transplant. 2007; 7: 394-401Crossref PubMed Scopus (157) Google Scholar Antibodies against human tissue (human leukocyte antigens [HLAs]) can develop in response to exposure to human tissue, and this poses another potential barrier to successful kidney transplantation. This commonly occurs after prior organ transplant, blood transfusion, or pregnancy.11Kanter Berga J. Sancho Calabuig A. Gavela Martinez E. et al.Pretransplant donor-specific HLA antibodies detected by single antigen bead flow cytometry: risk factors and outcomes after kidney transplantation.Transplant Proc. 2012; 44: 2529-2531Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 12Masson E. Vidal C. Deschamps M. et al.Incidence and risk factors of anti-HLA immunization after pregnancy.Hum Immunol. 2013; 74: 946-951Crossref PubMed Scopus (48) Google Scholar Anti-HLA antibodies are assessed at the time of listing for transplant and are reported as panel reactive antibodies (PRA). Individuals with a PRA of 80% or greater are considered highly sensitized to HLA antigens and less likely to be offered an immunologically compatible organ. Women are at risk for developing anti-HLA antibodies as a result of pregnancy. Multiple pregnancies, especially fathered by different men, are more likely to result in a broader array of HLA antibodies. Even in the absence of detectable anti-HLA antibodies at the time of evaluation for transplant, there is still a risk for an anamnestic response when a woman is exposed to tissue that has common HLA with her children. Blood transfusions, especially in the era before Leukopoor filters, and prior organ transplant are other mechanisms by which patients may be exposed to human tissue and therefore are at risk for the development of anti-HLA antibodies. Prior transplant is more likely to result in a stronger PRA than prior pregnancy or blood transfusion.13Hyun J. Park K.D. Yoo Y. et al.Effects of different sensitization events on HLA alloimmunization in solid organ transplantation patients.Transplant Proc. 2012; 44: 222-225Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Women on the wait list are more likely than men to have a positive PRA (60.3% vs 34.2% of men).13Hyun J. Park K.D. Yoo Y. et al.Effects of different sensitization events on HLA alloimmunization in solid organ transplantation patients.Transplant Proc. 2012; 44: 222-225Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Offspring or spouses often step forward as potential donors, but they may be incompatible with their mother or wife because of sensitization to the donor HLA from prior pregnancies. Over 30% of individuals on the deceased-donor wait list for a kidney are highly sensitized to HLA antigens (SRTR Annual Report 2011) and therefore are at risk for a prolonged waiting time before receiving an immunologically compatible kidney. Ultimately, 35.5% of women who are transplanted receive a living donor compared with 34.5% of men (based on OPTN data as of April 22, 2013). The types of living donors vary slightly based on gender and ethnicity (Table 1). Race and ethnicity are reported to United Network Organ Sharing at the time of candidate registration for wait-listing and are often self-reported and broadly categorized as White, Hispanic or Latino, Black or African American, Asian, Native American or Native Alaskan, Native Hawaiian or Pacific Islander, or other. White women are more likely to receive a living donor from a spouse or life partner (3.4%) as compared with minority (Black 1.2%, Hispanic 2.4%, or Asian 3.0%) women. This is in contrast to men, who receive a living-donor kidney from a spouse or life partner consistently more frequently: White men 5.5%, Blacks 2.2%, Hispanics 4.3%, and Asians 4.6%. Women are more likely than men to receive a kidney from their child, 5.1% vs 4.8%, and are more likely than men to receive a kidney from their parent (7.7% vs 4.2%). There are ethnic differences in the donation by other biologically related (other than parent or child) individuals to men and women. White women receive a biologically related kidney in 9.3% of cases as compared with 15.2% for white men. Living donation from donors who are biologically related, but not a parent or child, show less gender differences amongst non-white race recipients as compared with white recipients (Table 1). Some of these donor gender differences may be due to the inability of a primary income earner (often male) to take time off work. Other observed gender differences may be related to cultural influences. It is interesting that despite the barriers that may exist in women being referred for transplant, they are more likely than men to receive a living-donor transplant. The reasons for this have not been teased out in the literature, but they may be a result of education of family and friends about the living-donor process.Table 1Recipient Ethnicity and Type of Living-Kidney DonorRace/EthnicitySpouse/Life PartnerParentChildBiologically Related∗Biologically related (other than parent or child) includes cousins, full siblings, half siblings, and grandchildren. (Other Than Parent or Child)Paired DonationFemaleMaleFemaleMaleFemaleMaleFemaleMaleFemaleMaleOverall2.8%4.5%5.1%4.8%7.7%4.2%14.0%13.1%0.8%0.6%White3.5%5.5%6.3%5.8%6.1%5.8%9.3%15.2%0.8%0.7%Black1.2%2.2%2.4%2.2%7.0%3.2%9.1%7.2%0.8%0.7%Hispanic2.4%4.3%6.1%5.0%6.9%5.8%15.1%14.7%0.9%0.6%Asian3.0%4.6%3.2%3.7%4.3%3.4%12.6%12.2%1.1%0.8%∗ Biologically related (other than parent or child) includes cousins, full siblings, half siblings, and grandchildren. Open table in a new tab Outcomes for transplantation are measured as patient and graft survival at various time points and reported to the Scientific Registry of Transplant Recipients. Patient and kidney allograft survival are best with living-donor transplant. Patient survival with a living donor is generally similar for women and men at all time points of 3 months, 1 year, 5 years, and 10 years posttransplant (Table 2). At 5 years posttransplant, women have a slightly better survival than men (93.7% vs 92.8%), but at 10 years survival for women is essentially the same at 78.3% vs 79% for men.14Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1994-2013. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; United Network for Organ Sharing, Richmond, VA. University Renal Research and Education Association, Ann Arbor, MI2013Google Scholar Deceased-donor transplants do not offer the same degree of patient survival as living-donor transplants. Both recipient factors such as time on dialysis and comorbid conditions as well as donor factors play into patient and graft survival. Deceased donors are broadly categorized as standard criteria donor (SCD) kidneys vs extended criteria donor (ECD) kidneys. SCD kidneys are typically from deceased donors with a declaration of brain death and range in age from approximately 16 to 50 years of age. ECD kidneys are typically from deceased donors older than 60 years of age or deceased donors older than 50 years of age with 2 of the following 3 criteria: creatinine levels greater than 1.5 mg/dL, a history of hypertension, or death related to stroke. ECD kidneys are most often reserved for older recipients, typically older than 50 or 55 years of age. Patient survival for SCD kidneys is similar for women and men up to 5 years posttransplant (96.9% and 96.8% respectively), but it favors women by 10 years with a 68.6% survival for women and a 64.6% survival for men.14Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1994-2013. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; United Network for Organ Sharing, Richmond, VA. University Renal Research and Education Association, Ann Arbor, MI2013Google Scholar As might be expected, ECD kidneys are associated with less patient survival, likely as a result of being placed into older individuals. Overall patient survival for women with an ECD kidney transplant is 93.9% at 5 years posttransplant (93.8% for men), but it drops off markedly at 10 years to 47.1% for women and 42.4% of men.14Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1994-2013. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; United Network for Organ Sharing, Richmond, VA. University Renal Research and Education Association, Ann Arbor, MI2013Google Scholar However, this is still favorable to the overall patient survival for patients on dialysis.Table 2Patient and Graft Survival by Donor TypeDonor Type30-d1-y5-y10-yFemaleMaleFemaleMaleFemaleMaleFemaleMalePatient survival Living donor99.599.699.098.793.792.878.379.0 Non-ECD deceased donor98.898.896.996.888.388.568.664.6 ECD deceased donor97.697.593.693.974.673.147.142.4Graft survival Living donor97.998.796.496.983.684.361.262.3 Non-ECD deceased donor96.296.793.093.375.373.550.046.7 ECD deceased donor93.293.387.087.064.360.335.427.7Abbreviation: ECD, extended criteria donor. Open table in a new tab Abbreviation: ECD, extended criteria donor. Kidney allograft survival is superior with a living-donor transplant and similar for women and men at 3 months posttransplant (97.9% and 98.7%) and at 5 years (96.4% and 96.9%) and 10 years posttransplant (61.2% and 62.3%)14Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1994-2013. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; United Network for Organ Sharing, Richmond, VA. University Renal Research and Education Association, Ann Arbor, MI2013Google Scholar (Table 2). Many factors affect graft survival of non-ECD kidneys, including the age of the donor, the size of the donor, and a transplant center effect. There is little difference between men and women in graft survival of non-ECD kidneys. Graft survival at 3 months is 96.2% vs 92.7%, at 1 year 93.0% vs 93.3%, at 5 years 75.3% vs 73.5%, and at 10 years 50.0% vs 46.7%, respectively, for women vs men at each time point.14Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1994-2013. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; United Network for Organ Sharing, Richmond, VA. University Renal Research and Education Association, Ann Arbor, MI2013Google Scholar ECD kidneys are associated with a shorter graft survival—again, likely because of the nature of the kidneys being procured from an older individual. Graft survival rates for ECD kidneys are again similar for women and men during the first 5 years posttransplant, with graft survivals of 93.3% and 93.2% at 3 months, 87% for both women and men at 1 year, and 64.3% and 60.3% at 5 years posttransplant for women and men, but then they drop off significantly at 10 years to 35.4% and 27.7% for women and men, respectively.14Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1994-2013. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation; United Network for Organ Sharing, Richmond, VA. University Renal Research and Education Association, Ann Arbor, MI2013Google Scholar The long-term outcomes and complications for transplant recipients are similar for men and women, but there are unique concerns for women. Infection and malignancy concerns are directly related to suppression of T lymphocytes, resulting in susceptibility to viral and fungal infections and an impaired immune surveillance that keeps early cancers in check. As the primary care providers of children, women may be at greater risk than men for exposure to infections carried by children. The primary malignancies facing kidney transplant recipients are skin cancers, with a 10% to 30% risk of development within 10 to 20 years posttransplant that is largely dependent on skin type and sun exposure. Most skin cancers are nonmelanoma skin cancers, predominantly squamous cell cancers.15Muehleisen B. Pazhenkottil A. French L.E. Hofbauer G.L. Nonmelanoma skin cancer in organ transplant recipients: increase without delay after transplant and subsequent acceleration.JAMA Dermatol. 2013; 149: 618-620Crossref PubMed Scopus (8) Google Scholar, 16Geusau A. Dunkler D. Messeritsch E. et al.Non-melanoma skin cancer and its risk factors in an Austrian population of heart transplant recipients receiving induction therapy.Int J Dermatol. 2008; 47: 918-925Crossref PubMed Scopus (31) Google Scholar Vulvar and cervical cancer risk is increased in kidney transplant recipients, up to 50- and 15-fold, respectively.17Hinten F. Meeuwis K.A.P. van Rossum M.M. de Hullu J.A. HPV-related (pre)malignancies of the female anogenital tract in renal transplant recipients.Crit Rev Oncol Hematol. 2012; 84: 161-180Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar A quadrivalent vaccine against human papilloma virus (strains 6, 11, 16, and 18) was approved by the U.S. Food and Drug Administration in 2008. This vaccine protects against the strains of human papilloma virus that account for 70% (strains 16 and 18) of cervical cancers and 90% of genital warts.18Teitelman A.M. Stringer M. Averbuch T. Witkoski A. Human papillomavirus, current vaccines, and cervical cancer prevention.J Obstet Gynecol Neonatal Nurs. 2009; 38: 69-80Crossref PubMed Scopus (16) Google Scholar Hopefully, widespread use of this vaccine will decrease the incidence of cervical cancer in female transplant recipients. Women need to maintain regular gynecologic screening with a Papanicolaou test and treat abnormalities in a timely and appropriate manner. Breast cancer rates for female kidney transplant recipients are not greater, and may be slightly lower, than the general U.S. population.19Hall E.C. Pfeiffer R.M. Segev D.L. Engels E.A. Cumulative incidence of cancer after solid organ transplantation.Cancer. 2013; 119: 2300-2308Crossref PubMed Scopus (113) Google Scholar This may reflect the mandatory age-appropriate cancer screening before listing and during the wait-list period for transplant. Cardiovascular disease is the leading cause of death for transplant recipients more than 1 year out from transplant. Risk factors for development of cardiovascular disease include traditional Framingham risk factors in addition to transplant-related factors.20Ducloux D. Kazory A. Chalopin J. Predicting coronary heart disease in renal transplant recipients: a prospective study.Kidney Int. 2004; 66: 441-447Crossref PubMed Scopus (139) Google Scholar New-onset diabetes after transplant develops in approximately 30% of transplant recipients and is associated with the presence of the metabolic syndrome before transplant.21Bayer N.D. Cochetti P.T. Anil Kumar M. et al.Association of metabolic syndrome with development of new-onset diabetes after transplantation.Transplantation. 2010; 90: 861-866Crossref PubMed Scopus (58) Google Scholar Female gender was protective in developing posttransplant diabetes in one study of risk factors, demonstrating a 35% reduction by univariate analysis, although this did not hold under multivariate analysis.22Wauters R.P. Cosio F.G. Suarez Fernandez M.L. Kudva Y. Shah P. Torres V.E. Cardiovascular consequences of new-onset hyperglycemia after kidney transplantation.Transplantation. 2012; 94: 377-382Crossref PubMed Scopus (81) Google Scholar However, weight gain is common posttransplant and a contributing factor to posttransplant diabetes. In a study by Cosio,23Cosio F.G. Pesavento T.E. Kim S. Osei K. Henry M. Ferguson R.M. Patient survival after renal transplantation: IV. Impact of post-transplant diabetes.Kidney Int. 2002; 62: 1440-1446Crossref PubMed Google Scholar new-onset diabetes after transplant was associated with an 80% decreased patient survival, independent of other risk factors. Smoking after kidney transplant is associated with an increased risk of graft loss, increased risk of cardiovascular events, and increased risk of death.24Corbett C. Armstrong M.J. Neuberger J. Tobacco smoking and solid organ transplantation.Transplantation. 2012; 94 ([editorial]): 979-987Crossref PubMed Scopus (72) Google Scholar, 25Hurst F. Altieri M. Patel P. et al.Effect of smoking on kidney transplant outcomes: analysis of the United States Renal Data System.Transplantation. 2011; 92: 1101-1107Crossref PubMed Scopus (39) Google Scholar However, women are statistically less likely to be smokers posttransplant.25Hurst F. Altieri M. Patel P. et al.Effect of smoking on kidney transplant outcomes: analysis of the United States Renal Data System.Transplantation. 2011; 92: 1101-1107Crossref PubMed Scopus (39) Google Scholar Several recent studies document suboptimal management of cardiovascular risk factors.26Carpenter M.A. Weir M.R. Adey D.B. House A.A. Bostom A.G. Kusek J.W. Inadequacy of cardiovascular risk factor management in chronic kidney transplantation? Evidence from the FAVORIT study.Clin Transplant. 2012; 26: E438-E446Crossref PubMed Scopus (37) Google Scholar, 27Gaston R.S. Kasiske B.L. Fieberg A.M. et al.Use of cardioprotective medications in kidney transplant recipients.Am J Transplant. 2009; 9: 1811-1815Crossref PubMed Scopus (61) Google Scholar, 28Dawson K.L. Patel S.J. Putney D. Suki W.N. Osama Gaber A. Cardioprotective medication use after renal transplantation.Clin Transplant. 2010; 24: E253-E256Crossref PubMed Scopus (6) Google Scholar Diet and exercise need to be addressed at each physician visit after transplant. Dietary restrictions are relaxed after transplantation, and food is more palatable with the resolution of uremia, which puts patients at risk for weight gain. The benefits of exercise posttransplant are uniformly accepted in the population at large and can be extended to transplant recipients. Programmed and supervised exercise in kidney transplant recipients can improve VO2max in kidney transplant recipients, which can improve exercise capacity and sense of well being, although the effect on blood pressure and other cardiovascular risk factors is less clear.29Didsbury M. McGee R.G. Tong A. et al.Exercise training in solid organ transplant recipients: a systematic review and meta-analysis.Transplantation. 2013; 95: 679-687Crossref PubMed Scopus (100) Google Scholar, 30Painter P.L. Hector L. Ray K. et al.Effects of exercise training on coronary heart disease risk factors in renal transplant recipients.Am J Kidney Dis. 2003; 42: 362-369Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 31Painter P. Hector L. Ray K. et al.A randomized trial of exercise training after renal transplantation.Transplantation. 2002; 74: 42-48Crossref PubMed Scopus (163) Google Scholar, 32Naylor K.L. Li A.H. Lam N.N. Hodsman A.B. Jamal S.A. Garg A.X. Fracture risk in kidney transplant recipients: a systematic review.Transplantation. 2013; 95: 1461-1470Crossref PubMed Scopus (57) Google Scholar Bone loss, especially in women, has been a concern with the long-term use of glucocorticoids and has been one of the driving forces behind steroid minimization and steroid withdrawal protocols. Osteoporosis and risk of fracture is increased in women as compared with men and is exacerbated by transplant.32Naylor K.L. Li A.H. Lam N.N. Hodsman A.B. Jamal S.A. Garg A.X. Fracture risk in kidney transplant recipients: a systematic review.Transplantation. 2013; 95: 1461-1470Crossref PubMed Scopus (57) Google Scholar A study by Nikkel33Nikkel L.E. Mohan S. Zhang A. et al.Reduced fracture risk with early corticosteroid withdrawal after kidney transplant.Am J Transplant. 2012; 12: 649-659Crossref PubMed Scopus (94) Google Scholar demonstrated a 42% relative increased risk for fracture posttransplant. Increasing age, regardless of gender, was associated with an increased risk of fracture, with a 176% increase in risk for individuals in the 50- to 65-year age range and a 327% increased risk for individuals older than 65 years of age. Another study by Opelz34Opelz G. Döhler B. Association of mismatches for HLA-DR with incidence of posttransplant hip fracture in kidney transplant recipients.Transplantation. 2011; 91: 65-69Crossref PubMed Scopus (28) Google Scholar corroborated that the posttransplant fracture risk was increased for women, especially for women over 60 years of age who had a 5-fold increased risk of hip fracture. Most patients describe an improved quality of life posttransplant. In the first few months posttransplant there may be side effects of medications such as nausea, vomiting, diarrhea, and tremors. Hair loss is not uncommon in patients on a combination of mycophenolate and tacrolimus, with this often being a more common complaint in women. On the other hand, hirsuitism is common with cyclosporine preparations, and again this side effect is more noticeable in women, especially those with a darker complexion. Complaints of low energy are frequent in the early weeks to months after transplantation and can be exacerbated by anemia, especially in menstruating women. Sexual problems improve after transplant for men and women; however, even after transplant 44% of women still have complaints related to lack of interest in sex, lack of enjoyment, or problems with sexual arousal.35Diemon W. Vruggink P. Meuleman E. Doesburg W. Lemmens W. Berden J. Sexual dysfunction after renal replacement therapy.Am J Kidney Dis. 2000; 35: 845-851Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar The fear of kidney rejection is always looming for transplant recipients. In the current era of immunosuppression, acute rejection rates are low, approximately 10% or less. Despite this fact, one of the greatest expressed fears of transplant recipients is rejection. Coping mechanisms play a role in how transplant recipients deal with this stress. Women are more likely than men to have a sense of intrusive anxiety and feeling of loss of control.36Nilsson M. Forsberg A. Bäckman L. Lennerling A. Persson L. The perceived threat of the risk for graft rejection and health-related quality of life among organ transplant recipients.J Clin Nurs. 2011; 20: 274-282Crossref PubMed Scopus (26) Google Scholar, 37Nilsson M, Forsberg A, Lennerling A, Persson L. Coping in relation to perceived threat of the risk of graft rejection and health-related quality of life of organ transplant recipients. Scand J Caring Sci. http://dx.doi.org/10.1111/scs.12007.Google Scholar It is interesting to note that the stress associated with fear of rejection is not associated with time since transplant, although acute rejection episodes diminish over time. Public opinion generally supports the concept of living donation, especially a directed donation to a known recipient (84.4%) vs an unknown recipient (33%).38Tong A, Chapman JR, Wong G, Josephson MA, Craig JC. Public awareness and attitudes to living organ donation: systematic review and integrative synthesis. Transplantation. http://dx.doi.org/10.1097/TP.0b013e31829282ac.Google Scholar Altruistic organ donation is increasing. A small study of altruistic donors showed that women were more likely to step forward than men to be an altruistic kidney donor, although this was not statistically significant.39Rodrigue J.R. Schutzer M.E. Paek M. Morrissey P. Altruistic kidney donation to a stranger: psychosocial and functional outcomes at two US transplant centers.Transplantation. 2011; 91: 772-778PubMed Google Scholar The main barrier to pursing living-organ donation was a concern regarding donor health. Living donors are more likely to be women, with 58.7% of living donors being female. Most (47%) living-kidney donors are between the ages of 35 and 49 years of age, 30% are in the 18 to 34 age range, 22% are between the ages of 50 and 64 years, and just over 1% are older than 65 years of age. Of living donors who are women, 74% are White, 12% are Black, 12% are Hispanic, and 3% are Asian, which is similar to the ethnic breakdown for male living donors. The age breakdown is slightly different for male living donors, with 39% being between the ages of 18 and 34 years, 41% being 35 to 49 years of age, 18% being 50 to 64 years of age, and 1% being older than 65 years of age. This slight difference in age distribution between women and men in coming forward as a living donor may reflect men being in a position of being a primary financial support for the family and not being able to take time off work. One cannot dismiss psychosocial contributions behind the increased likelihood that women step forward as living donors more frequently then men. Women are more likely to be caregivers and have sense of an obligation to come foreword as a living donor, especially for a family member. The psychological effect of living organ donation cannot be quantified, but it can be assessed qualitatively. Donors typically report no adverse effect of organ donation and typically report an improvement in the mental component of quality of life.40Joshi S.A. Almeida N. Almeida A. Assessment of the perceived quality of life of successful kidney transplant recipients and their donors pre- and post-transplantation.Transplant Proc. 2013; 45: 1435-1437Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 41Lopes A. Frade I.C. Teixeira L. Almeida M. Dias L. Henriques A.C. Quality of life assessment in a living donor kidney transplantation program: evaluation of recipients and donors.Transplant Proc. 2013; 45: 1106-1109Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Depression is more common amongst women than men, but donors are less likely than the general population to experience depression.42Lentine K.L. Schnitzler M.A. Xiao H. et al.Depression diagnoses after living kidney donation: linking U.S. registry data and administrative claims.Transplantation. 2012; 94: 77-83Crossref PubMed Scopus (58) Google Scholar Death of the recipient or graft loss was associated with an increased risk of depression and was more pronounced in the case of nonspousal, unrelated recipients. The availability of deceased-donor organs is limited for many reasons, including the preexisting wishes of the newly deceased, family discomfort with the process, distrust of the medical system, and many other reasons.43Irving M.J. Tong A. Jan S. et al.Community attitudes to deceased organ donation: a focus group study.Transplantation. 2012; 93: 1064-1069Crossref PubMed Scopus (36) Google Scholar, 44Jacoby L. Jaccard J. Perceived support among families deciding about organ donation for their loved ones: donor vs nondonor next of kin.Am J Crit Care. 2010; 19: e52-e61Crossref PubMed Scopus (70) Google Scholar Family perception of how they were approached and supported have a marked influence on the decision to donate. Deceased donors are more likely to be male than female (optn.transplant.hrsa.org). The ideal deceased donor is typically in the 18-to 34-year age range because they are typically healthy until encountering a serious injury. The adolescent or young adult male stereotypically is considered to be at higher risk for engaging in behaviors that may result in serious injury. Of deceased donors, 48% are women, mostly between 35 and 49 years of age. This is in contrast to male deceased donors, who are more likely to be in the 18- to 34-year age range (36% of male deceased donors). In most cases the cause of death was not reported. When documented, the most frequently reported causes of death were motor vehicle accident or cerebrovascular accident. Kidney transplantation remains the treatment of choice for most patients with CKD. The gap between those being listed for transplant and those receiving a kidney transplant continues to widen. Short of decreasing the incidence of kidney disease, the only approach to narrowing this gap is through education about organ donation, both in the arena of live-organ donation and deceased-organ donation. Women appear to be referred for transplantation less frequently than men. However, women are more likely to receive a living-donor transplant. Women are more likely than men to step forward as a living donor, especially as a donor to their spouse.