Recipient sex and estradiol levels affect transplant outcomes in an age-specific fashion

Am J Transplant. 2021 Oct;21(10):3239-3255. doi: 10.1111/ajt.16611. Epub 2021 Jun 24.


Sex-specific influences have been shown for a variety of diseases. Whether donor or recipient sex and sex hormone levels impact alloimmune responses remains unclear. In unifactorial and multifactorial analyses of more than 400 000 SRTR listed kidney transplant patients, we found that younger female recipients had an inferior death-censored graft survival that was independent of donor sex. In contrast, graft survival was superior in older female recipients, suggesting the impact of recipient sex hormones over chromosomal sex mismatches. Those clinical changes were delineated in experimental skin and heart transplant models showing a prolongation of graft survival in ovariectomized young female recipients. In contrast, graft survival was comparable in ovariectomized and naïve old female recipients. Young ovariectomized mice showed reduced amounts and a compromised T cell proliferation. Deprivation of female hormones dampened the production of interferon (IFN)-γ and interleukin (IL)-17+ by CD4+ T cells while augmenting systemic counts of Tregs. Increasing estradiol concentrations in vitro promoted the switch of naïve CD4+ T cells into Th1 cells; high physiological estradiol concentrations dampening Th1 responses, promoted Tregs, and prolonged graft survival. Thus, clinical observations demonstrate age-specific graft survival patterns in female recipients. Estrogen levels, in turn, impact the fate of T cell subsets, providing relevant and novel information on age- and sex-specific alloimmunity.

Keywords: basic (laboratory) research/science; endocrinology/diabetology; gender; kidney failure/injury; kidney transplantation/nephrology; organ allocation; organ transplantation in general; rejection: T cell mediated (TCMR); reproductive biology.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Animals
  • Estradiol
  • Female
  • Graft Rejection / etiology
  • Graft Survival*
  • Humans
  • Kidney Transplantation* / adverse effects
  • Male
  • Mice
  • Tissue Donors


  • Estradiol