ASSOCIATIONS OF CULTURAL AND LINGUISTIC DIVERSITY WITH KIDNEY TRANSPLANT OUTCOMES IN AUSTRALIA AND NEW ZEALAND

Equity in access and outcomes after kidney transplantation remains a challenge in multicultural societies. While culturally and linguistically diverse (CALD) populations are known to experience disparities in access to kidney transplantation, their post-transplant outcomes have been less well characterised. We aimed to examine the impact of CALD status on patient and graft survival following kidney transplantation in Australia and New Zealand.

We included all non-Indigenous adults currently living in Australia or New Zealand who received a kidney transplant between 2002-2023 as reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. We followed-up patients from the date of transplant until the outcome of interest or censored them at the last known follow-up on 31 December 2023. Patients were categorised into three groups: 1) Aus/NZ (individuals born in Australia/New Zealand), 2) CALD-English (born in predominantly English-speaking countries), and 3) CALD-non-English (born elsewhere). Outcomes of interest were patient survival, death with functioning graft, overall graft survival and death-censored graft survival. Kaplan-Meier and log-rank tests assessed unadjusted outcomes. Multivariable Cox proportional hazards and Fine-Gray competing risks models estimated adjusted (sub)hazard ratios (HRs/SHRs) for CALD status, accounting for clinical, demographic, and socioeconomic factors. Sensitivity analyses included donor stratification, re-transplants and reported ethnicity.

We studied 13,828 kidney transplant recipients (64% male, mean age 50±13 years), the majority of whom were Aus/NZ-born (68.8%). Compared with Aus/NZ, CALD-non-English were older at transplant, more likely to receive deceased-donor kidneys, and had higher rates of diabetic kidney disease, late referral, lower socioeconomic status, and residence in major cities (Table 1). Median patient survival was 20.5 years in Aus/NZ, compared with 18.4 years in CALD-English, and 19.1 years in CALD-non-English, while median graft survival was 14.8 years in Aus/NZ, 13.1 years in CALD-English and 13.9 years in CALD-non-English. Kaplan-Meier analyses showed that patient, overall graft, and death-censored graft survival were broadly similar across the three groups (Figure 1). However, after adjustment for relevant variables, CALD-non-English had significantly lower mortality compared with Aus/NZ (HR 0.75, 95% CI 0.67-0.85, p<0.001), while no significant difference was observed for CALD-English. The risk of death with a functioning graft was also lower in CALD-non-English (SHR 0.74, 95% CI 0.66-0.83, p<0.001) and CALD-English (SHR 0.82, 95% CI 0.68-0.99, p<0.05) compared with Aus/NZ. In contrast, we found no significant differences in overall or death-censored graft survival between CALD groups and Aus/NZ, aside from a modest survival advantage for CALD-non-English in the adjusted Cox model (HR 0.86, 95% CI 0.79-0.94, p<0.05) (Table 2). Where reported ethnicity was additionally included in the model, CALD-English also demonstrated significantly lower mortality compared with Aus/NZ. Findings were consistent in sensitivity analyses stratified by donor type and re-transplant status.

CALD status, particularly among CALD-non-English recipients, is independently associated with improved long-term survival following kidney transplantation. This finding challenges the assumption that cultural and language barriers inherently lead to poorer outcomes and suggests that strong family and community support may contribute to this survival advantage. These results extend previous evidence from dialysis cohorts and reinforce the need to ensure timely access to transplantation for CALD populations.