Gender disparity in access to care across the continuum of chronic kidney disease: a systematic review.

BACKGROUND: 'Gender' as a social construct is increasingly recognized as a determinant of care inequity in chronic kidney disease (CKD). However, a systematic analysis of gender-based disparity in access to care across the continuum of CKD care is lacking. This systematic review aimed to synthesize the global evidence on gender-based disparities in access observed across sequential steps of CKD care. METHODS: The review was registered in PROSPERO (CRD420251091356) and conducted following PRISMA guidelines. Four databases (PubMed, Cochrane, HINARI, Embase) were searched for publications from 2000-July 2026. Two reviewers independently screened 1,140 articles and risk of bias was assessed using ROBINS-E. Data were extracted across four aspects of CKD care: (1) diagnosis, monitoring and prescription of guideline-recommended treatment, (2) vascular access, (3) initiation and maintenance of dialysis, and (4) transplantation. RESULTS: Thirty-five studies were included, spanning diverse geographical regions. Women faced consistent disadvantages across the continuum of CKD care. They had lower odds of receiving a diagnosis of CKD or nephrology referral, less frequent monitoring of kidney function, and lower prescription rates of guideline-recommended medications. Among those with kidney failure, women comprised only 38-41% of prevalent dialysis patients and initiated dialysis at lower estimated glomerular filtration rates (8.1-10.1 vs. 10.6 mL/min/1.73 m² in men). Women were less likely to initiate haemodialysis with arteriovenous fistulae (AVF) and less likely to transition to AVF later while prevalent on dialysis compared to men. Throughout the transplant pathway, women with CKD were less likely to have transplantation discussed as an option, referred for evaluation, waitlisted, or transplanted. Both systemic and socioeconomic mechanisms contributed to these disparities. CONCLUSION: Sex and gender-based inequities systematically disadvantage women across the entire CKD care continuum. These findings highlight the need to integrate policies to ensure gender-equity in the management of CKD.