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Abstract
In the general population with COVID-19, the male sex is an established risk factor for mortality, in part due to a more robust immune response to COVID-19 in women. Because patients on kidney function replacement therapy (KFRT) have an impaired immune response, especially kidney transplant recipients due to their use of immunosuppressants, we examined whether the male sex is still a risk factor for mortality among patients on KFRT with COVID-19. From the European Renal Association COVID-19 Database (ERACODA), we examined patients on KFRT with COVID-19 who presented between February 1st, 2020, and April 30th, 2021. 1204 kidney transplant recipients (male 62.0%, mean age 56.4 years) and 3206 dialysis patients (male 61.8%, mean age 67.7 years) were examined. Three-month mortality in kidney transplant recipients was 16.9% in males and 18.6% in females (p = 0.31) and in dialysis patients 27.1% in males and 21.9% in females (p = 0.001). The adjusted HR for the risk of 3-month mortality in males (vs females) was 0.89 (95% CI 65, 1.23, p = 0.49) in kidney transplant recipients and 1.33 (95% CI 1.13, 1.56, p = 0.001) in dialysis patients (pinteraction = 0.02). In a fully adjusted model, the aHR for the risk of 3-month mortality in kidney transplant recipients (vs. dialysis patients) was 1.39 (95% CI 1.02, 1.89, p = 0.04) in males and 2.04 (95% CI 1.40, 2.97, p < 0.001) in females (pinteraction = 0.02). In patients on KFRT with COVID-19, the male sex is not a risk factor for mortality among kidney transplant recipients but remains a risk factor among dialysis patients. The use of immunosuppressants in kidney transplant recipients, among other factors, may have narrowed the difference in the immune response to COVID-19 between men and women, and therefore reduced the sex difference in COVID-19 mortality risk.
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1 University Medical Center Groningen, University of Groningen, Department Internal Medicine, Groningen, The Netherlands (GRID:grid.4494.d) (ISNI:0000 0000 9558 4598); University Medical Center Groningen, Department of Clinical Pharmacy & Pharmacology, Groningen, The Netherlands (GRID:grid.4494.d) (ISNI:0000 0000 9558 4598)
2 Radboud University Medical Center, Department of Nephrology, Nijmegen, The Netherlands (GRID:grid.10417.33) (ISNI:0000 0004 0444 9382)
3 Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands (GRID:grid.414846.b) (ISNI:0000 0004 0419 3743)
4 Grigore T Popa University of Medicine and Pharmacy, Iasi, Romania (GRID:grid.411038.f) (ISNI:0000 0001 0685 1605); Dr Ci Parhon Hospital, Iasi, Romania (GRID:grid.411038.f)
5 Helsinki University Central Hospital and Helsinki University, Helsinki, Finland (GRID:grid.15485.3d) (ISNI:0000 0000 9950 5666)
6 Zuyderland Ziekenhuis, Sittard-Geleen, The Netherlands (GRID:grid.15485.3d)
7 Satakunta Central Hospital, Pori, Finland (GRID:grid.415303.0)
8 University Medical Center Groningen, University of Groningen, Department Internal Medicine, Groningen, The Netherlands (GRID:grid.4494.d) (ISNI:0000 0000 9558 4598)
9 Tergooi Medical Center, Hilversum, The Netherlands (GRID:grid.413202.6) (ISNI:0000 0004 0626 2490)
10 Amsterdam UMC Location University of Amsterdam, Medical Informatics, ERA Registry, Amsterdam, The Netherlands (GRID:grid.509540.d) (ISNI:0000 0004 6880 3010); Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands (GRID:grid.16872.3a) (ISNI:0000 0004 0435 165X)
11 Albert Schweitzer Hospital, Dordrecht, The Netherlands (GRID:grid.413972.a) (ISNI:0000 0004 0396 792X)
12 APHP Paris-Saclay University, Ambroise Pare Hospital, Boulogne Billancourt, France (GRID:grid.413756.2) (ISNI:0000 0000 9982 5352)
13 Amphia Hospital, Breda, The Netherlands (GRID:grid.413711.1) (ISNI:0000 0004 4687 1426)
14 Amsterdam UMC, Amsterdam, The Netherlands (GRID:grid.509540.d) (ISNI:0000 0004 6880 3010)
15 Antwerp University Hospital, Antwerp, Belgium (GRID:grid.411414.5) (ISNI:0000 0004 0626 3418)
16 Avicennes Military Hospital, Cadi Ayyad University, Faculty of Medicine, Marrakech, Morocco (GRID:grid.411840.8) (ISNI:0000 0001 0664 9298)
17 AZ Delta, Roeselare, Belgium (GRID:grid.478056.8) (ISNI:0000 0004 0439 8570)
18 B. Braun Avitum, Litomerice, Czech Republic (GRID:grid.484911.1) (ISNI:0000 0004 0402 7796)
19 Bellvitge University Hospital, Hospitalet de Llobregat, Barcelona, Spain (GRID:grid.411129.e) (ISNI:0000 0000 8836 0780)
20 Bernhoven Hospital, Uden, The Netherlands (GRID:grid.470077.3) (ISNI:0000 0004 0568 6582)
21 Bravis Hospital, Roosendaal/Bergen Op Zoom, The Netherlands (GRID:grid.470077.3)
22 Cantonal Hospital Zenica, Zenica, Bosnia and Herzegovina (GRID:grid.470077.3)
23 ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest, Romania (GRID:grid.8194.4) (ISNI:0000 0000 9828 7548); Emergency Clinical Hospital ‘Sf. Ioan’, Bucharest, Romania (GRID:grid.8194.4)
24 Catharina Hospital, Eindhoven, The Netherlands (GRID:grid.413532.2) (ISNI:0000 0004 0398 8384)
25 Central Clinical Hospital of the Ministry of Interior, Warsaw, Poland (GRID:grid.413635.6) (ISNI:0000 0004 0620 5920)
26 Centre Hospitalier du Nord, Ettelbruck, Luxembourg (GRID:grid.418041.8) (ISNI:0000 0004 0578 0421)
27 Centre of Postgraduate Medical Education, Warsaw, Poland (GRID:grid.414852.e) (ISNI:0000 0001 2205 7719)
28 Centrodial, São João da Madeira, Portugal (GRID:grid.414852.e)
29 Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal (GRID:grid.418336.b) (ISNI:0000 0000 8902 4519)
30 City Hospital N.a. S.P. Botkin, Moscow, Russia (GRID:grid.418336.b)
31 City Hospital Zürich, Zurich, Switzerland (GRID:grid.418336.b)
32 Claude Galien Hospital Ramsay Santé, Quincy-Sous-Sénart, France (GRID:grid.418336.b)
33 Clínica de Hemodiálise de Felgueiras, Felgueiras, Portugal (GRID:grid.418336.b)
34 University of Novi Sad, Clinical Centre of Vojvodina & Faculty of Medicine Novi Sad, Novi Sad, Serbia (GRID:grid.10822.39) (ISNI:0000 0001 2149 743X)
35 Croatian Society of Nephrology, Dialysis and Transplantation, Zagreb, Croatia (GRID:grid.10822.39)
36 CWZ Nijmegen, Nijmegen, The Netherlands (GRID:grid.413327.0) (ISNI:0000 0004 0444 9008)
37 DaVita Geilenkirchen, Geilenkirchen, Germany (GRID:grid.413327.0)
38 DaVita, Wrocław, Poland (GRID:grid.413327.0)
39 Aristotle University of Thessaloniki, 1St Department of Internal Medicine, Medical School, Thessaloniki, Greece (GRID:grid.4793.9) (ISNI:0000000109457005)
40 Deventer Ziekenhuis, Deventer, The Netherlands (GRID:grid.413649.d) (ISNI:0000 0004 0396 5908)
41 Dianet Dialysis Center, Utrecht, The Netherlands (GRID:grid.490071.b) (ISNI:0000 0004 0499 2158)
42 Dialysis Center Bochum, Bochum, Germany (GRID:grid.490071.b)
43 Dnipro State Medical University, Dnipro, Ukraine (GRID:grid.512994.2) (ISNI:0000 0004 0400 3807)
44 Elyse Klinieken Voor Nierzorg, Kerkrade, The Netherlands (GRID:grid.512994.2)
45 High Institute of Public Health-Alexandria University, Epidemiology Department, Alexandria, Egypt (GRID:grid.7155.6) (ISNI:0000 0001 2260 6941)
46 Erasme Hospital, Brussels, Belgium (GRID:grid.412157.4) (ISNI:0000 0000 8571 829X)
47 University Medical Center Rotterdam, Department of Internal Medicine, Erasmus MC Transplant Institute, Rotterdam, The Netherlands (GRID:grid.5645.2) (ISNI:000000040459992X)
48 Charles University, Faculty of Medicine in Pilsen, Pilsen, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X)
49 Faculty of Medicine-Alexandria University, Alexandria, Egypt (GRID:grid.7155.6) (ISNI:0000 0001 2260 6941)
50 Franciscus Gasthuis & Vlietland, Schiedam, The Netherlands (GRID:grid.461048.f) (ISNI:0000 0004 0459 9858)
51 Freeman Hospital, Newcastle Upon Tyne, UK (GRID:grid.415050.5) (ISNI:0000 0004 0641 3308)
52 Fundació Puigvert, Barcelona, Spain (GRID:grid.418813.7) (ISNI:0000 0004 1767 1951)
53 Fundación Jiménez Díaz, Madrid, Spain (GRID:grid.419651.e) (ISNI:0000 0000 9538 1950)
54 Gdansk Medical University, Gdansk, Poland (GRID:grid.11451.30) (ISNI:0000 0001 0531 3426)
55 Gelre Hospital, Apeldoorn, The Netherlands (GRID:grid.415355.3) (ISNI:0000 0004 0370 4214)
56 General Hospital of Athens “G. Gennimatas”, Athens, Greece (GRID:grid.414012.2) (ISNI:0000 0004 0622 6596)
57 General Hospital of Serres, Serres, Greece (GRID:grid.415457.6) (ISNI:0000 0004 0623 1221)
58 General University Hospital of Alexandroupolis, Alexandroupolis, Greece (GRID:grid.412483.8) (ISNI:0000 0004 0622 4099)
59 Grande Ospedale Metropolitano and CNR, Reggio Calabria, Italy (GRID:grid.412483.8)
60 Haaglanden Medisch Centrum, The Hague, The Netherlands (GRID:grid.411038.f)
61 Haga Hospital, The Hague, The Netherlands (GRID:grid.413591.b) (ISNI:0000 0004 0568 6689)
62 Hospital Clínic de Barcelona, Barcelona, Spain (GRID:grid.410458.c) (ISNI:0000 0000 9635 9413)
63 Hospital Curry Cabral-Central Lisbon University Hospital Center, Lisbon, Portugal (GRID:grid.413362.1) (ISNI:0000 0000 9647 1835)
64 Universidade Federal de Minas Gerais, Hospital das Clinicas, Belo Horizonte, Brazil (GRID:grid.8430.f) (ISNI:0000 0001 2181 4888)
65 Hospital del Mar, Barcelona, Spain (GRID:grid.411142.3) (ISNI:0000 0004 1767 8811)
66 Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal (GRID:grid.411142.3)
67 Hospital Gelderse Vallei, Ede, The Netherlands (GRID:grid.415351.7) (ISNI:0000 0004 0398 026X)
68 Hospital General of Alicante, Alicante, Spain (GRID:grid.411086.a) (ISNI:0000 0000 8875 8879)
69 Hospital General Universitario Gregorio Marañón, Madrid, Spain (GRID:grid.410526.4) (ISNI:0000 0001 0277 7938)
70 Hospital Obispo Polanco, Salud Aragón, Spain (GRID:grid.414940.c) (ISNI:0000 0004 1794 9861)
71 Hospital Universitario Ramón y Cajal, Madrid, Spain (GRID:grid.411347.4) (ISNI:0000 0000 9248 5770)
72 Imelda Hospital, Bonheiden, Belgium (GRID:grid.414579.a) (ISNI:0000 0004 0608 8744)
73 Isala, Zwolle, The Netherlands (GRID:grid.452600.5) (ISNI:0000 0001 0547 5927)
74 Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey (GRID:grid.9601.e) (ISNI:0000 0001 2166 6619)
75 Jeroen Bosch Ziekenhuis, Den Bosch, The Netherlands (GRID:grid.413508.b) (ISNI:0000 0004 0501 9798)
76 Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany (GRID:grid.419800.4) (ISNI:0000 0000 9321 629X)
77 Leiden University Medical Center, Leiden, The Netherlands (GRID:grid.10419.3d) (ISNI:0000000089452978)
78 Lister Hospital, Stevenage, UK (GRID:grid.415953.f) (ISNI:0000 0004 0400 1537)
79 Lithuanian University of Health Sciences, Kaunas, Lithuania (GRID:grid.45083.3a) (ISNI:0000 0004 0432 6841)
80 Luzerner Kantonsspital, Luzern, Switzerland (GRID:grid.413354.4) (ISNI:0000 0000 8587 8621)
81 Maasstad Ziekenhuis, Rotterdam, The Netherlands (GRID:grid.416213.3) (ISNI:0000 0004 0460 0556)
82 Maastricht University Medical Center, Maastricht, The Netherlands (GRID:grid.412966.e) (ISNI:0000 0004 0480 1382)
83 Manipal Hospital, Manipal, India (GRID:grid.416383.b) (ISNI:0000 0004 1768 4525)
84 Marche Nord Hospital, Pesaro, Italy (GRID:grid.416383.b)
85 Marmara University School of Medicine, Istanbul, Turkey (GRID:grid.16477.33) (ISNI:0000 0001 0668 8422)
86 Martini Ziekenhuis, Groningen, The Netherlands (GRID:grid.416468.9) (ISNI:0000 0004 0631 9063)
87 Maxima Medisch Centrum, Veldhoven, The Netherlands (GRID:grid.414711.6) (ISNI:0000 0004 0477 4812)
88 Meander Medisch Centrum, Amersfoort, The Netherlands (GRID:grid.414725.1) (ISNI:0000 0004 0368 8146)
89 Medical University Innsbruck, Innsbruck, Austria (GRID:grid.5361.1) (ISNI:0000 0000 8853 2677)
90 Medical University of Vienna, Vienna, Austria (GRID:grid.22937.3d) (ISNI:0000 0000 9259 8492)
91 Moscow Regional Research and Clinical Institute, Moscow, Russia (GRID:grid.467082.f)
92 Necmettin Erbakan University Meram School of Medicine, Konya, Turkey (GRID:grid.17242.32) (ISNI:0000 0001 2308 7215)
93 University of Parma, Nephrology Unit, Department of Medicine and Surgery, Parma, Italy (GRID:grid.10383.39) (ISNI:0000 0004 1758 0937)
94 Nierenzentrum Reutlingen-Tübingen, Reutlingen, Germany (GRID:grid.10383.39)
95 Oslo University Hospital–Rikshospitalet, Norwegian Renal Registry, Olso, Norway (GRID:grid.55325.34) (ISNI:0000 0004 0389 8485)
96 Okinawa Chubu Hospital, Uruma, Japan (GRID:grid.416827.e) (ISNI:0000 0000 9413 4421)
97 OLVG, Amsterdam, The Netherlands (GRID:grid.440209.b) (ISNI:0000 0004 0501 8269)
98 Ospedale S. Maurizio Bolzano, Bolzano, Italy (GRID:grid.440209.b)
99 Padua University Hospital, Padua, Italy (GRID:grid.411474.3) (ISNI:0000 0004 1760 2630)
100 Radboud University Medical Center, Nijmegen, The Netherlands (GRID:grid.10417.33) (ISNI:0000 0004 0444 9382)
101 Regional Clinical Hospital, Yaroslavl, Russia (GRID:grid.10417.33)
102 Regional Hospital of Malaga, Malaga, Spain (GRID:grid.10417.33)
103 Rijnstate Hospital, Arnhem, The Netherlands (GRID:grid.415930.a)
104 RUDN University, Moscow, Russia (GRID:grid.77642.30) (ISNI:0000 0004 0645 517X)
105 Saint-Petersburg State University Hospital, Saint-Petersburg, Russia (GRID:grid.15447.33) (ISNI:0000 0001 2289 6897)
106 University of Catania, San Marco Hospital, Catania, Italy (GRID:grid.8158.4) (ISNI:0000 0004 1757 1969)
107 Saxenburgh Medisch Centrum, Hardenberg, The Netherlands (GRID:grid.8158.4)
108 Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands (GRID:grid.415960.f) (ISNI:0000 0004 0622 1269)
109 Southern Health and Social Care Trust, Newry, Northern Ireland (GRID:grid.487411.f) (ISNI:0000 0004 0393 1572)
110 Spaarne Gasthuis, Haarlem, The Netherlands (GRID:grid.416219.9) (ISNI:0000 0004 0568 6419)
111 SPWSZ Hospital, Szczecinie, Poland (GRID:grid.416219.9)
112 St. Anna University Hospital, Ferrara, Italy (GRID:grid.416315.4)
113 St. Bassiano Hospital, Bassano del Grappo, Italy (GRID:grid.416315.4)
114 Streekziekenhuis Koningin Beatrix, Winterswijk, The Netherlands (GRID:grid.415484.8) (ISNI:0000 0004 0568 7286)
115 Swedish Renal Registry, Jönköping, Sweden (GRID:grid.415484.8)
116 Tehran University of Medical Sciences, Tehran, Iran (GRID:grid.411705.6) (ISNI:0000 0001 0166 0922)
117 Charles University, and Faculty Hospital Kralovske Vinohrady, Third Faculty of Medicine, Prague, Czech Republic (GRID:grid.4491.8) (ISNI:0000 0004 1937 116X)
118 Toledo University Hospital, Toledo, Spain (GRID:grid.4491.8)
119 Treant/Scheper Ziekenhuis, Emmen, The Netherlands (GRID:grid.4491.8)
120 Turgut Ozal Medical Center, Malatya, Turkey (GRID:grid.417351.5) (ISNI:0000 0004 0471 8933)
121 Université Catholique de Louvain, Cliniques Universitaires St Luc, Brussels, Belgium (GRID:grid.48769.34) (ISNI:0000 0004 0461 6320)
122 University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain (GRID:grid.411048.8) (ISNI:0000 0000 8816 6945)
123 University Clinical Hospital of Valladolid, Valladolid, Spain (GRID:grid.411057.6) (ISNI:0000 0000 9274 367X)
124 Universitary Hospital of Guadalajara, Guadalajara, Spain (GRID:grid.411098.5) (ISNI:0000 0004 1767 639X)
125 University Hospital Leuven, Leuven, Belgium (GRID:grid.410569.f) (ISNI:0000 0004 0626 3338)
126 University Hospital Brussels, Brussels, Belgium (GRID:grid.411326.3) (ISNI:0000 0004 0626 3362)
127 University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Martin, Slovakia (GRID:grid.449102.a)
128 University Hospital Medical Center Verona, Verona, Italy (GRID:grid.411475.2) (ISNI:0000 0004 1756 948X)
129 University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK (GRID:grid.15628.38) (ISNI:0000 0004 0393 1193)
130 University Hospital of Ioannina, Ioannina, Greece (GRID:grid.411740.7) (ISNI:0000 0004 0622 9754)
131 University Hospital of Patras, Patras, Greece (GRID:grid.412458.e)
132 University Medical Center Groningen, Groningen, The Netherlands (GRID:grid.4494.d) (ISNI:0000 0000 9558 4598)
133 University Medical Center Ljubljana, Ljubljana, Slovenia (GRID:grid.29524.38) (ISNI:0000 0004 0571 7705)
134 University Medical Centre Maribor, Maribor, Slovenia (GRID:grid.412415.7) (ISNI:0000 0001 0685 1285)
135 University Medical Center Utrecht, Utrecht, The Netherlands (GRID:grid.7692.a) (ISNI:0000000090126352)
136 University of California Irvine School of Medicine, Orange, USA (GRID:grid.266093.8) (ISNI:0000 0001 0668 7243)
137 University of Genoa, Genoa, Italy (GRID:grid.5606.5) (ISNI:0000 0001 2151 3065)
138 University of Liège, Liège, Belgium (GRID:grid.4861.b) (ISNI:0000 0001 0805 7253)
139 University of Milan, Milan, Italy (GRID:grid.4708.b) (ISNI:0000 0004 1757 2822)
140 University of Navarra Clinic, Pamplona, Spain (GRID:grid.411730.0) (ISNI:0000 0001 2191 685X)
141 University of Piemonte Orientale, Novara, Italy (GRID:grid.16563.37) (ISNI:0000000121663741)
142 Sion & Lausanne University Hospital, Valais Hospital, Lausanne, Switzerland (GRID:grid.8515.9) (ISNI:0000 0001 0423 4662)
143 Vall d’Hebron University Hospital, Barcelona, Spain (GRID:grid.411083.f) (ISNI:0000 0001 0675 8654)
144 VieCuri Medical Centre, Venlo, The Netherlands (GRID:grid.416856.8) (ISNI:0000 0004 0477 5022)
145 Vilnius University, Vilnius, Lithuania (GRID:grid.6441.7) (ISNI:0000 0001 2243 2806)
146 Vimercate Hospital, Vimercate, Italy (GRID:grid.413643.7) (ISNI:0000 0004 1760 8047)
147 Zonguldak Ataturk State Hospital, Zonguldak, Turkey (GRID:grid.413643.7)