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The effect of sex inequality on solid organ transplantation: A systematic review and meta-analysis

  • Author Footnotes
    1 ST and RMR contributed equally as first author.
    Sofia Tejada
    Footnotes
    1 ST and RMR contributed equally as first author.
    Affiliations
    Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain

    Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
    Search for articles by this author
  • Author Footnotes
    1 ST and RMR contributed equally as first author.
    Raquel Martinez-Reviejo
    Footnotes
    1 ST and RMR contributed equally as first author.
    Affiliations
    Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain

    Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain
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  • Taísa A. Nogueira
    Affiliations
    Universidade Federal de Campina Grande, Campina Grande, Brazil
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  • Aroa Gómez
    Affiliations
    Department of Donor & Transplant Coordination, Vall d'Hebron University Hospital, Barcelona, Spain
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  • Teresa Pont
    Affiliations
    Department of Donor & Transplant Coordination, Vall d'Hebron University Hospital, Barcelona, Spain
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  • Xuelian Liao
    Affiliations
    Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China

    West China Tianfu Hospital, Sichuan University, Chengdu, China
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  • Zheng Zhang
    Affiliations
    Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
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  • Oriol Manuel
    Affiliations
    Service of Infectious Diseases, Lausanne University Hospital, Lausanne, Switzerland

    Transplantation Center, Lausanne University Hospital, Lausanne, Switzerland
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  • Jordi Rello
    Correspondence
    Corresponding author.
    Affiliations
    Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institut of Research (VHIR), Barcelona, Spain

    Clinical Research CHU Nîmes, Université de Nîmes-Montpellier, France

    Medicine Department, Universitat Internacional de Catalunya (UIC), Sant Cugat, Spain
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  • Author Footnotes
    1 ST and RMR contributed equally as first author.
Published:December 28, 2022DOI:https://doi.org/10.1016/j.ejim.2022.12.009

      Highlights

      • Why carry out this study?
      • Does sex matter? The importance of sex inequalities in solid organ transplantation.
      • There is limited evidence assessing the impact of sex on transplant recipient outcomes.
      • What was learned from the study?
      • Females account for 1/3 of the solid organ transplant recipient's cohort and have higher survival than males after liver and kidney transplant.
      • Allograft dysfunction was influenced by combination of donor-recipient sex and age.
      • Consider sex as a factor to optimize the management of transplant patients.

      Abstract

      Background

      Sex disparities are related to biological differences, which may have significant impact on patient and allograft outcomes. The aim was to investigate the impact of sex on clinical and safety outcomes after solid organ transplantation (SOT).

      Methods

      A systematic review and meta-analysis was performed. Observational studies comparing females vs. males after SOT were considered for inclusion after a systematic search of the Pubmed, Cochrane Library, and Web of Science databases conducted from 2016 to 2021. Primary outcome was mortality. PROSPERO register number: CRD42021282615.

      Results

      After retrieving 1103 studies, 22 observational studies (1,045,380 subjects) were finally deemed eligible for inclusion. Females accounted 36.3% of SOT recipients, but presented significantly lower mortality (odds ratio (OR): 0.87, 95% confidence interval (CI): 0.83–0.92, I2=78%). In subgroup analyses, mortality was significantly lower in females undergoing liver (OR: 0.89 95%CI: 0.86–0.92, I2=0%) or kidney transplantation (OR: 0.82 95%CI: 0.76–0.89, I2=72%). Male sex was consistently reported as a protective factor against hospital readmission. Among the outcomes, allograft dysfunction was influenced by a combination of donor-recipient sex and age. Data on overall infections were inconclusive. Several reports suggest a higher risk of malignancy among males.

      Conclusions

      Females represent one-third of SOT recipients but have higher survival rates than males after liver and kidney transplantation. The impact on graft dysfunction was heterogeneous. While further research is warranted, our findings should encourage clinicians and researchers to consider sex as a factor when taking decisions regarding SOT management.

      Keywords

      Abbreviations:

      SOT (Solid Organ Transplantation), RMLH (restricted maximum likelihood), CI (Confidence Interval), OR (Odds Ratio), HR (Hazard ratio), MELD-Na (Model for End-Stage Liver Disease incorporating sodium levels), PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis)
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      References

        • Kaleta B.
        Osteopontin and transplantation: where are we now?.
        Arch Immunol Ther Exp. 2021; 69: 15https://doi.org/10.1007/s00005-021-00617-6
        • Kotton C.N.
        CMV: prevention, diagnosis and therapy.
        Am J Transplant. 2013; 13: 24-40https://doi.org/10.1111/ajt.12006
        • Cozzi E.
        • Colpo A.
        • De Silvestro G.
        The mechanisms of rejection in solid organ transplantation.
        Transfus Apher Sci. 2017; 56: 498-505https://doi.org/10.1016/j.transci.2017.07.005
        • Cohen E.
        • Korah M.
        • Callender G.
        • Belfort de Aguiar R.
        • Haakinson D.
        Metabolic disorders with kidney transplant.
        Clin J Am Soc Nephrol. 2020; 15: 732-742https://doi.org/10.2215/CJN.09310819
        • Kute V.B.
        • Chauhan S.
        • Navadiya V.V.
        • Meshram H.S.
        • Patel H.V.
        • Engineer D.
        • et al.
        India: gender disparities in organ donation and transplantation.
        Transplantation. 2022; 106: 1293-1297https://doi.org/10.1097/TP.0000000000003960
        • Yeow M.
        • Soh S.
        • Wong J.
        • Tan E.
        • Ganpathi Iyer S.
        Gender diversity in transplantation leadership positions in transplantation journals and organizations.
        Transplantation. 2022; 106: e352-e353https://doi.org/10.1097/TP.0000000000004123
        • Darden M.
        • Parker G.
        • Anderson E.
        • Buell J.F
        Persistent sex disparity in liver transplantation rates.
        Surgery. 2021; 169: 694-699https://doi.org/10.1016/j.surg.2020.06.028
        • Laprise C.
        • Cole K.
        • Sridhar V.S.
        • Marenah T.
        • Crimi C.
        • West L.
        • et al.
        Sex and gender considerations in transplant research: a scoping review.
        Transplantation. 2019; 103: e239https://doi.org/10.1097/TP.0000000000002828
        • Miller A.J.
        • Kiberd B.A.
        • Alwayn I.P.
        • Odutayo A.
        • Tennankore K.K.
        Donor-recipient weight and sex mismatch and the risk of graft loss in renal transplantation.
        Clin J Am Soc Nephrol. 2017; 12: 669-676https://doi.org/10.2215/CJN.07660716
        • Sarkar M.
        • Watt K.D.
        • Terrault N.
        • Berenguer M.
        Outcomes in liver transplantation: does sex matter?.
        J Hepatol. 2015; 62: 946-955https://doi.org/10.1016/j.jhep.2014.11.023
        • Ayesta A.
        • Urrútia G.
        • Madrid E.
        • Vernooij R.W.M.
        • Vicent L.
        • Martínez-Sellés M.
        Sex-mismatch influence on survival after heart transplantation: a systematic review and meta-analysis of observational studies.
        Clin Transplant. 2019; 33: e13737https://doi.org/10.1111/ctr.13737
        • Puoti F.
        • Ricci A.
        • Nanni-Costa A.
        • Ricciardi W.
        • Malorni W.
        • Ortona E.
        Organ transplantation and gender differences: a paradigmatic example of intertwining between biological and sociocultural determinants.
        Biol Sex Differ. 2016; 7: 35https://doi.org/10.1186/s13293-016-0088-4
        • Klein S.L.
        • Marriott I.
        • Fish E.N.
        Sex-based differences in immune function and responses to vaccination.
        Trans R Soc Trop Med Hyg. 2015; 109: 9-15https://doi.org/10.1093/trstmh/tru167
        • Bouman A.
        • Heineman M.J.
        • Faas M.M.
        Sex hormones and the immune response in humans.
        Hum. Reprod. Update. 2005; 11: 411-423https://doi.org/10.1093/humupd/dmi008
        • Tan J.C.
        • Wadia P.P.
        • Coram M.
        • Grumet F.C.
        • Kambham N.
        • Miller K.
        • et al.
        H-Y antibody development associates with acute rejection in female patients with male kidney transplants.
        Transplantation. 2008; 86: 75-81https://doi.org/10.1097/TP.0b013e31817352b9
        • Melk A.
        • Babitsch B.
        • Borchert-Mörlins B.
        • Claas F.
        • Dipchand A.I.
        • Eifert S.
        • et al.
        Equally interchangeable? How sex and gender affect transplantation.
        Transplantation. 2019; 103: 1094-1110https://doi.org/10.1097/TP.0000000000002655
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • Mulrow C.
        • Gøtzsche P.C.
        • Ioannidis J.P.A.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        J Clin Epidemiol. 2009; 62: e1-34https://doi.org/10.1016/j.jclinepi.2009.06.006
        • Higgins J.P.T.
        • Thomas J.
        • Chandler J.
        • Cumpston M.
        • Li T.
        • Page M.J.
        • et al.
        Cochrane handbook for systematic reviews of interventions.
        John Wiley & Sons, 2019
        • Klinge I.
        • Wiesemann C.
        Sex and gender in biomedicine - theories, methodologies, results.
        (editors) Universitätsverlag Göttingen, 2010https://doi.org/10.17875/gup2010-394
      1. Wells G., Shea B., O'Connell D., Peterson J., Welch V., Losos M., et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ott Hosp Res Inst Nd n.d. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.

        • Hozo S.P.
        • Djulbegovic B.
        • Hozo I.
        Estimating the mean and variance from the median, range, and the size of a sample.
        BMC Med Res Methodol. 2005; 5: 13https://doi.org/10.1186/1471-2288-5-13
        • Wan X.
        • Wang W.
        • Liu J.
        • Tong T.
        Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range.
        BMC Med Res Methodol. 2014; 14: 135https://doi.org/10.1186/1471-2288-14-135
        • Higgins J.P.T.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560https://doi.org/10.1136/bmj.327.7414.557
        • Egger M.
        • Davey Smith G.
        • Schneider M.
        • Minder C
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634https://doi.org/10.1136/bmj.315.7109.629
        • Berenguer M.
        • Di Maira T.
        • Baumann U.
        • Mirza D.F.
        • Heneghan M.A.
        • Klempnauer J.L.
        • et al.
        Characteristics, trends, and outcomes of liver transplantation for primary sclerosing cholangitis in female versus male patients: an analysis from the European Liver Transplant Registry.
        Transplantation. 2021; 105: 2255-2262https://doi.org/10.1097/TP.0000000000003542
        • Bhat M.
        • Mara K.
        • Dierkhising R.
        • Watt K.D.S.
        Immunosuppression, race, and donor-related risk factors affect de novo cancer incidence across solid organ transplant recipients.
        Mayo Clin Proc. 2018; 93: 1236-1246https://doi.org/10.1016/j.mayocp.2018.04.025
        • Bhat M.
        • Mara K.
        • Dierkhising R.
        • Watt K.D.
        Gender, race and disease etiology predict de novo malignancy risk after liver transplantation: insights for future individualized cancer screening guidance.
        Transplantation. 2019; 103: 91-100https://doi.org/10.1097/TP.0000000000002113
        • Dedinská I.
        • Graňák K.
        • Vnučák M.
        • Skálová P.
        • Kováčiková L.
        • Laca Ľ.
        • et al.
        Role of sex in post-transplant diabetes mellitus development: are men and women equal?.
        J Diabetes Complications. 2019; 33: 315-322https://doi.org/10.1016/j.jdiacomp.2018.12.017
        • do Nascimento Carvalho W.
        • Alves Maria G.D.S.
        • Gonçalves K.C.
        • Miranda A.L.
        • Moreira M da C.V
        Impacts of social inequalities on the survival of heart transplant recipients in a developing country.
        Clin Transplant. 2021; 35: e14129https://doi.org/10.1111/ctr.14129
        • Ferreira F.R.
        • Ogawa M.M.
        • Nascimento L.F.C.
        • Tomimori J.
        Risk factors for nonmelanoma skin cancer in renal transplant recipients: a case-control study from a reference outpatient clinic in Southeast Brazil.
        Int J Dermatol. 2017; 56: 154-160https://doi.org/10.1111/ijd.13508
        • García-Cosío M.D.
        • González-Vilchez F.
        • López-Vilella R.
        • Barge-Caballero E.
        • Gómez-Bueno M.
        • Martínez-Selles M.
        • et al.
        Gender differences in heart transplantation: twenty-five year trends in the nationwide Spanish heart transplant registry.
        Clin Transplant. 2020; 34: e14096https://doi.org/10.1111/ctr.14096
        • Germani G.
        • Zeni N.
        • Zanetto A.
        • Adam R.
        • Karam V.
        • Belli L.S.
        • et al.
        Influence of donor and recipient gender on liver transplantation outcomes in Europe.
        Liver Int Off J Int Assoc Study Liver. 2020; 40: 1961-1971https://doi.org/10.1111/liv.14510
        • Haugen C.E.
        • King E.A.
        • Bae S.
        • Bowring M.G.
        • Holscher C.M.
        • Garonzik-Wang J.
        • et al.
        Early hospital readmission in older and younger kidney transplant recipients.
        Am J Nephrol. 2018; 48: 235-241https://doi.org/10.1159/000492338
        • Hickey K.T.
        • Doering L.V.
        • Chen B.
        • Carter E.V.
        • Sciacca R.R.
        • Pickham D.
        • et al.
        Clinical and gender differences in heart transplant recipients in the NEW HEART study.
        Eur J Cardiovasc Nurs. 2017; 16: 222-229https://doi.org/10.1177/1474515116651178
        • Kadakia S.
        • Taghavi S.
        • Jayarajan S.
        • Ambur V.
        • Wheatley G.
        • Kaiser L.
        • et al.
        Examining mortality and rejection in combined heart-lung transplantations.
        Thorac Cardiovasc Surg. 2017; 65: 423-429https://doi.org/10.1055/s-0036-1597989
        • Lee B.P.
        • Dodge J.L.
        • Terrault N.A.
        Excess mortality after liver transplantation in young women with alcohol-associated liver disease.
        Am J Gastroenterol. 2021; 116: 551-559https://doi.org/10.14309/ajg.0000000000001007
        • Lepeytre F.
        • Dahhou M.
        • Zhang X.
        • Boucquemont J.
        • Sapir-Pichhadze R.
        • Cardinal H.
        • et al.
        Association of sex with risk of kidney graft failure differs by age.
        J Am Soc Nephrol. 2017; 28: 3014-3023https://doi.org/10.1681/ASN.2016121380
        • Magnussen C.
        • Ruebsamen N.
        • Ojeda F.M.
        • Rybczynski M.
        • Kobashigawa J.
        • Reichenspurner H.
        • et al.
        Sex differences in preformed panel-reactive antibody levels and outcomes in patients undergoing heart transplantation.
        Clin Transplant. 2019; 33: e13572https://doi.org/10.1111/ctr.13572
        • Mahmud N.
        • Halpern S.
        • Farrell R.
        • Ventura K.
        • Thomasson A.
        • Lewis H.
        • et al.
        An advanced practice practitioner-based program to reduce 30- and 90-day readmissions after liver transplantation.
        Liver Transpl. 2019; 25: 901-910https://doi.org/10.1002/lt.25466
        • Matsuoka L.
        • Izzy M.
        • Feurer I.D.
        • Rega S.A.
        • Ziogas I.A.
        • SP Alexopoulos
        Sex and gender disparities in pretransplant characteristics and relationships with postoperative outcomes in liver transplant recipients with alcoholic liver disease.
        Exp Clin Transplant. 2020; 18: 701-706https://doi.org/10.6002/ect.2020.0063
        • Melk A.
        • Schmidt B.M.W.
        • Geyer S.
        • Epping J.
        Sex disparities in dialysis initiation, access to waitlist, transplantation and transplant outcome in German patients with renal disease-A population based analysis.
        PLoS ONE. 2020; 15e0241556https://doi.org/10.1371/journal.pone.0241556
        • Moayedi Y.
        • Fan C.P.S.
        • Cherikh W.S.
        • Stehlik J.
        • Teuteberg J.J.
        • Ross H.J.
        • et al.
        Survival outcomes after heart transplantation: does recipient sex matter?.
        Circ Heart Fail. 2019; 12e006218https://doi.org/10.1161/CIRCHEARTFAILURE.119.006218
        • Morgan G.
        • Goolam-Mahomed Z.
        • Hodson J.
        • Nath J.
        • Sharif A.
        Donor-recipient sex differences do not affect survival outcomes after kidney transplantation: a population cohort study.
        Transplantation. 2020; 104: 1033-1040https://doi.org/10.1097/TP.0000000000002915
        • Patel M.S.
        • Mohebali J.
        • Shah J.A.
        • Markmann J.F.
        • Vagefi P.A.
        Readmission following liver transplantation: an unwanted occurrence but an opportunity to act.
        HPB (Oxford). 2016; 18: 936-942https://doi.org/10.1016/j.hpb.2016.08.003
        • Sheikh S.I.
        • Hayes D.
        • Kirkby S.E.
        • Tobias J.D.
        • Tumin D.
        Age-dependent gender disparities in post lung transplant survival among patients with idiopathic pulmonary fibrosis.
        Ann Thorac Surg. 2017; 103: 441-446https://doi.org/10.1016/j.athoracsur.2016.08.083
        • Wajda N.
        • Zhu Z.
        • Jandarov R.
        • Dilling D.F.
        • Gupta N.
        Clinical outcomes and survival following lung transplantation in patients with pulmonary Langerhans cell histiocytosis.
        Respirology. 2020; 25: 644-650https://doi.org/10.1111/resp.13671
        • Guerra A.A.
        • Cesar C.C.
        • Cherchiglia M.L.
        • Andrade E.I.G.
        • de Queiroz O.V.
        • Silva G.D.
        • et al.
        Cyclosporine versus tacrolimus in immunosuppressive maintenance regimens in renal transplants in Brazil: survival analysis from 2000 to 2004.
        Ann Pharmacother. 2010; 44: 192-201https://doi.org/10.1345/aph.1M244
        • T A.M.
        • Chng R.
        • Yau W.-.P
        Efficacy and safety of tacrolimus-based maintenance regimens in de novo kidney transplant recipients: a systematic review and network meta-analysis of randomized controlled trials.
        Ann Transplant. 2021; 26e933588https://doi.org/10.12659/AOT.933588
        • Jones-Hughes T.
        • Snowsill T.
        • Haasova M.
        • Coelho H.
        • Crathorne L.
        • Cooper C.
        • et al.
        Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model.
        Health Technol Assess Winch Engl. 2016; 20: 1-594https://doi.org/10.3310/hta20620
        • Freeman R.B.
        • Paya C.
        • Pescovitz M.D.
        • Humar A.
        • Dominguez E.
        • Washburn K.
        • et al.
        Risk factors for cytomegalovirus viremia and disease developing after prophylaxis in high-risk solid-organ transplant recipients.
        Transplantation. 2004; 78: 1765-1773https://doi.org/10.1097/01.tp.0000142619.01510.a5
        • Buxeda A.
        • Redondo-Pachón D.
        • Pérez-Sáez M.J.
        • Crespo M.
        • Pascual J.
        Sex differences in cancer risk and outcomes after kidney transplantation.
        Transplant Rev Orlando Fla. 2021; 35100625https://doi.org/10.1016/j.trre.2021.100625
        • Denhaerynck K.
        • Steiger J.
        • Bock A.
        • Schäfer-Keller P.
        • Köfer S.
        • Thannberger N.
        • et al.
        Prevalence and risk factors of non-adherence with immunosuppressive medication in kidney transplant patients.
        Am J Transplant. 2007; 7: 108-116https://doi.org/10.1111/j.1600-6143.2006.01611.x
        • Kiley D.J.
        • Lam C.S.
        • Pollak R.
        A study of treatment compliance following kidney transplantation.
        Transplantation. 1993; 55: 51-56https://doi.org/10.1097/00007890-199301000-00010
        • Feldman H.I.
        • Fazio I.
        • Roth D.
        • Berlin J.A.
        • Brayman K.
        • Burns J.E.
        • et al.
        Recipient body size and cadaveric renal allograft survival.
        J Am Soc Nephrol. 1996; 7: 151-157https://doi.org/10.1681/ASN.V71151
        • Oh C.-.K.
        • Lee B.M.
        • KO Jeon
        • Kim H.J.
        • Pelletier S.J.
        • Kim S.I.
        • et al.
        Gender-related differences of renal mass supply and metabolic demand after living donor kidney transplantation.
        Clin Transplant. 2006; 20: 163-170https://doi.org/10.1111/j.1399-0012.2005.00459.x
        • Klein S.L.
        • Flanagan K.L.
        Sex differences in immune responses.
        Nat Rev Immunol. 2016; 16: 626-638https://doi.org/10.1038/nri.2016.90
        • Foster B.J.
        • Dahhou M.
        • Zhang X.
        • Platt R.W.
        • Hanley J.A.
        Relative importance of HLA mismatch and donor age to graft survival in young kidney transplant recipients.
        Transplantation. 2013; 96: 469-475https://doi.org/10.1097/TP.0b013e318298f9db
        • Vinson A.J.
        • Zhang X.
        • Dahhou M.
        • Süsal C.
        • Döhler B.
        • Sapir-Pichhadze R.
        • et al.
        Age-dependent sex differences in graft loss after kidney transplantation.
        Transplantation. 2022; 106: 1473-1484https://doi.org/10.1097/TP.0000000000004026
        • Trigunaite A.
        • Dimo J.
        • Jørgensen T.N.
        Suppressive effects of androgens on the immune system.
        Cell Immunol. 2015; 294: 87-94https://doi.org/10.1016/j.cellimm.2015.02.004
        • Alvaro D.
        • Mancino M.G.
        • Onori P.
        • Franchitto A.
        • Alpini G.
        • Francis H.
        • et al.
        Estrogens and the pathophysiology of the biliary tree.
        World J Gastroenterol. 2006; 12: 3537-3545https://doi.org/10.3748/wjg.v12.i22.3537
        • Liermann Garcia R.F.
        • Evangelista Garcia C.
        • McMaster P.
        • Neuberger J
        Transplantation for primary biliary cirrhosis: retrospective analysis of 400 patients in a single center.
        Hepatology. 2001; 33: 22-27https://doi.org/10.1053/jhep.2001.20894
        • Little R.
        • Wine E.
        • Kamath B.M.
        • Griffiths A.M.
        • Ricciuto A.
        Gut microbiome in primary sclerosing cholangitis: a review.
        World J Gastroenterol. 2020; 26: 2768-2780https://doi.org/10.3748/wjg.v26.i21.2768
        • Doycheva I.
        • Leise M.D.
        • Watt K.D.
        The intestinal microbiome and the liver transplant recipient: what we know and what we need to know.
        Transplantation. 2016; 100: 61-68https://doi.org/10.1097/TP.0000000000001008
        • Główczyńska R.
        • Galas M.
        • Witkowska A.
        • Ołdakowska-Jedynak U.
        • Raszeja-Wyszomirska J.
        • Krasuski K.
        • et al.
        The pre-transplant profile of cardiovascular risk factors and its impact on long-term mortality after liver transplantation.
        Ann Transplant. 2018; 23: 591-597https://doi.org/10.12659/AOT.908771
        • Waki K.
        UNOS Liver Registry: ten year survivals.
        Clin Transpl. 2006; : 29-39
        • Duffy J.P.
        • Kao K.
        • Ko C.Y.
        • Farmer D.G.
        • McDiarmid S.V.
        • Hong J.C.
        • et al.
        Long-term patient outcome and quality of life after liver transplantation: analysis of 20-year survivors.
        Ann Surg. 2010; 252: 652-661https://doi.org/10.1097/SLA.0b013e3181f5f23a
        • Wechsler M.E.
        • Giardina E.G.
        • Sciacca R.R.
        • Rose E.A.
        • Barr M.L.
        Increased early mortality in women undergoing cardiac transplantation.
        Circulation. 1995; 91: 1029-1035https://doi.org/10.1161/01.cir.91.4.1029
        • Banchs H.L.
        • González V.
        • González Cancel I.
        • Quintana C.
        • Calderón R.
        • Altieri P.I
        Heart transplantation in females: the experience in Puerto Rico.
        Bol Asoc Med P R. 2005; 97: 248-256
        • Gabel S.A.
        • Walker V.R.
        • London R.E.
        • Steenbergen C.
        • Korach K.S.
        • Murphy E.
        Estrogen receptor beta mediates gender differences in ischemia/reperfusion injury.
        J Mol Cell Cardiol. 2005; 38: 289-297https://doi.org/10.1016/j.yjmcc.2004.11.013
        • Dziarmaga R.
        • Ke D.
        • Sapir-Pichhadze R.
        • Cardinal H.
        • Phan V.
        • Piccirillo C.A.
        • et al.
        Age- and sex-mediated differences in T lymphocyte populations of kidney transplant recipients.
        Pediatr Transplant. 2022; 26: e14150https://doi.org/10.1111/petr.14150
        • Fedotcheva T.A.
        • Fedotcheva N.I.
        • Shimanovsky N.L.
        Progesterone as an anti-inflammatory drug and immunomodulator: new aspects in hormonal regulation of the inflammation.
        Biomolecules. 2022; 12: 1299https://doi.org/10.3390/biom12091299
        • LoMauro A.
        • Aliverti A.
        Sex and gender in respiratory physiology.
        Eur Respir Rev. 2021; 30210038https://doi.org/10.1183/16000617.0038-2021