1. Why don’t indigenous dialysis patients receive transplants – waitlist or allocation? N. Khanal 1, P. Clayton 1, S. McDonald 1, M. Jose 2 1 The University of Adelaide, School of Medicine & ANZDATA Registry, Adelaide, Australia 2 University of Tasmania/ Royal Hobart Hospital, School of Medicine/ Department of Nephrology, Hobart- Tasmania, Australia

2. Introduction Disparities in access to kidney transplantation for indigenous Australians have been reported. Is it lower rates of placement on the waiting list? Is it lower likelihood of transplantation once on the waiting list?

3. Background

5. Objective We examined – The likelihood of placement of indigenous (Aboriginal and Torres Strait Islanders) Australians in the transplant waiting list (TWL), compared with non- indigenous Australians – The likelihood of transplantation once on the waiting list

6. Methods Records from the ANZDATA registry and NOMS for all adult Australians (18 - 60 years) who started RRT between 28 June 2006 and 31 December 2013 were analysed. They were divided into 2 groups: Indigenous non-indigenous The database records the race of the patients as they have identified themselves to their treating hospital

7. RRTTWLTx Non-Indigenous=6098 Indigenous=1380 Non-indigenous=2501 Indigenous=131

8. Operational definition Time to waitlisting – duration from renal replacement therapy start to being active on the waiting list Waiting time – duration from the first time a patient was active on the waiting list until transplantation. It was censored for living donor transplantation, death or end of follow-up.

9. Results INDIGENOUS Participants waiting to be waitlisted* Participants waiting for transplant * Current Smoker 2.51 (2.19, 2.87) 2.73 (1.81, 4.13) Diabetes (Type 1 & Type 2 ) 8.57 (7.37, 9.96) 7.30 (4.94-10.77) Coronary artery disease 2.41 (2.11, 2.75) 2.53 (1.62-3.95) Cerebrovascular disease 1.25 (1.03, 1.52) 1.14 (0.49-2.66) Peripheral vascular disease 1.97 (1.71, 2.27) 2.45 (1.49-4.02) Chronic lung disease 1.77 (1.51, 2.07) 1.64 (0.88-3.05) Table 1: * OR- Odds Ratio (95% CI- confidence interval) for Comorbidities adjusted for age, sex and remoteness

10. *Age-40, gender, BMI-normal, comorbidities, remoteness, and late-referral Kaplan Meier curve of the unadjusted time to waitlisting for indigenous and non- indigenous Fully adjusted* Kaplan Meier curve of the time to waitlisting for indigenous and non-indigenous

11. Results Unadjusted Adjusted # 1 st year Adjusted # 2 nd year onwards Hazard ratio (95% CI*) 0.17 (0.14, 0.20) 0.10 (0.05, 0.20) 0.24 (0.16, 0.37) P-value <0.001 Likelihood of waitlisting *CI confidence interval # Age, gender, BMI, comorbidities, late-referral, remoteness

12. Younger Vs. Older participants

13. Kaplan Meier curve of the time to waitlisting for indigenous and non- indigenous with and without diabetes Kaplan Meier curve of the time to waitlisting for indigenous and non- indigenous for year of RRT start categorised as 2006-2009; 2010-2013

14. Kaplan Meier curve of time to transplant for patients on TWL Likelihood of transplantation Hazard ratio (95% CI*) 1.11 (0.94, 1.33) P-value0.22

15. Transplantation by transplanting state Indigenous Non-Indigenous

16. Conclusions Among people receiving RRT in Australia, Indigenous Australians are less likely to be wait-listed. – These disparities are not be explained by measured comorbidities – This disparity was particularly marked in the first year, but persisted throughout the period of follow-up There is no difference in likelihood of receiving a renal transplant once waitlisted