*Purpose: We examined the relationship between sex and the relative importance of pros and cons in kidney transplant (KT) decision making.

*Methods: A convenience sample of adults on dialysis from Toronto completed the Decisional Balance Survey. Sex was self-identified as “Male” and “Female” (exposure). Patients rated the importance of potentially positive and negative outcomes to their decision about transplant on a scale ranging from 1 to 5 (‘not important’ to ‘extremely important’). Living donor KT (LDKT) and deceased donor KT (DDKT) pro and con scores were calculated by summing individual item scores. Items were then dichotomized (not/slightly/moderately vs very/extremely important) and their association with sex was analyzed in multivariable logistic regression models.

*Results: Of the 526 participants (mean [SD] age 57 [14] years) 37% were female. Sociodemographic characteristics were similar, except female participants were less likely to be married (42% vs 59%, p=0.002). The median [IQR] LDKT pro (18[15,21] vs 17[13,20]; p=0.037) and LDKT con (13[8,18] vs 12[8,17]; p=0.363) scores were similar between females and males. However, females rated DDKT pro (20[17,23 vs 19[16,22]; p=0.001) and DDKT con (12[7,16] vs 9[5,14]; p<0.001) significantly higher. None of the individual LDKT items, nor the DDKT pro items were significantly associated with sex. However, five out of the six DDKT con items were strongly associated with sex, but the "risk of dying during surgery" was not. These associations remained significant after adjusting for sociodemographic variables, comorbidity, ethnicity and transplant knowledge. For example, compared to males, females were twice as likely to indicate that the anticipated pain during surgery (OR=2.21, CI=1.36-3.58, p=0.002), the need to take a lot of medication after transplant (OR=1.97, CI=1.31-2.95, p=0.001) and concerns about being able to pay for transplant drugs (OR=2.60, CI=1.63-4.16, p<0.001) were very/extremely important to their transplant decision-making.

*Conclusions: When making transplant decisions, female kidney patients were more concerned about potential pain, and the cost of immunosuppressive drugs than males. Further qualitative research is needed to better understand these sex-specific differences in decision making to enable more tailored support to issues concerning to women to ensure equitable access to transplant.

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