Charles Darwin University

Organ Transplantation in Australia

Inequities in Access and Outcome for Indigenous Australians

Lawton, Paul D.; McDonald, Stephen P.; Snelling, Paul L.; Hughes, Jaquelyne; Cass, Alan

Published in:Transplantation

DOI:10.1097/TP.0000000000001911

Published: 01/11/2017

Document VersionPeer reviewed version

Link to publication

Citation for published version (APA):Lawton, P. D., McDonald, S. P., Snelling, P. L., Hughes, J., & Cass, A. (2017). Organ Transplantation inAustralia: Inequities in Access and Outcome for Indigenous Australians. Transplantation, 101(11), e345-e346.https://doi.org/10.1097/TP.0000000000001911

General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.

• Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal

Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.

Download date: 30. May. 2020

Copyright © Wolters Kluwer Health. Unauthorized reproduction of this article is prohibited.

Transplantation Publish Ahead of PrintDOI: 10.1097/TP.0000000000001911

1

Organ Transplantation in Australia: Inequities in Access and Outcome for

Indigenous Australians

Paul D. Lawton, MBBS FRACP PhD 1

Stephen P. McDonald, MBBS(Hons) FRACP PhD 2

Paul L. Snelling, MBChB BMedSci FRACP 3

Jaquelyne Hughes, BMed FRACP PhD 1,4

Alan Cass, MBBS BA FRACP PhD 1

1Menzies School of Health Research, Charles Darwin University, Darwin, Australia

2ANZDATA Registry & Royal Adelaide Hospital, Adelaide, Australia

3Statewide Renal Services, Royal Prince Alfred Hospital, Sydney, Australia

4Royal Darwin Hospital, Darwin, Australia

Correspondence information:

Paul D Lawton

Menzies School of Health Research

P.O. Box 41096

Casuarina, NT, 0811

Australia

paul.lawton@menzies.edu.au

ACCEPTED

Copyright © Wolters Kluwer Health. Unauthorized reproduction of this article is prohibited.

2

Authorship:

Paul Lawton and Alan Cass drafted this letter to the editor, which was reviewed and edited by

Stephen McDonald, Paul Snelling and Jaquelyne Hughes. All authors take responsibility for

the completed work.

Disclosure:

All authors have extensive experience working with Indigenous Australians with end-stage

kidney disease. The authors declare no other conflicts of interest.

Funding:

Paul Lawton is supported by a National Health and Medical Research Council (NHMRC)

Early Career Fellowship (#1120640). Jaquelyne Hughes is supported by an NHMRC Early

Career Fellowship (#1092576).

Abbreviations:

ESKD – end stage kidney disease

NHMRC – National Health and Medical Research Council of Australia

RRT – renal replacement therapy

USA – United States of America

ACCEPTED

Copyright © Wolters Kluwer Health. Unauthorized reproduction of this article is prohibited.

3

We agree with the authors about the successes of organ transplantation in Australia 1.

However, we would like to highlight the lack of access to kidney transplantation and

insufficient progress in maximising graft survival for Indigenous Australians.

Indigenous Australians have at least 6 times the age-standardised incidence of end-

stage kidney disease (ESKD) requiring renal replacement therapy (RRT) as non Indigenous

Australians. Among adults aged 25 to 64 and people from remote areas, rates are up to 15

times higher. Although constituting only 3.0% of the Australian population, over 1 in 10

patients commencing RRT each year in Australia are Indigenous. At the end of 2015, 1647

(13.2%) of 12 461 patients receiving dialysis treatment in Australia were Indigenous; in

contrast, only 241 (2.3%) of 10 551 patients with a functioning kidney transplant were

Indigenous 2

.

Waitlisting for deceased donor kidney transplantation is uncommon for Indigenous

patients. At the end of 2015, 1.9% of all Indigenous dialysis patients were on the waiting list,

in contrast to 9.5% of non Indigenous patients 2

. This leads to lower transplantation rates.

When all else is equal, Indigenous Australians have a quarter the chance of non Indigenous

patients of receiving a kidney transplant, with rates broadly like those in USA, Canada and

New Zealand 3

. Indigenous patients understand the potential advantages of kidney

transplantation and want access to this treatment modality, but concerns among kidney

specialists about poorer outcomes for Indigenous Australian patients compared to non

Indigenous patients appear to be a major reason for nonreferral for deceased donor waitlisting

4.

Posttransplantation outcomes for Indigenous Australians have indeed been worse than

those for non Indigenous Australians. Analysis of national registry data shows that

Indigenous kidney transplant recipients, after adjustment for age and comorbidity, had almost

ACCEPTED

Copyright © Wolters Kluwer Health. Unauthorized reproduction of this article is prohibited.

4

twice the risk of death of non Indigenous recipients between 2000 and 2012, and a 60%

increased chance of losing a kidney transplant. Unlike non Indigenous kidney transplant

recipients (in whom cardiac and cancer causes predominate), and in contrast with widespread

perceptions that immunosuppressive medication noncompliance is the major problem

amongst Indigenous patients4, infection has been the dominant cause of death or kidney

transplant loss.

However, in the presence of inequity in access to kidney transplantation, is it

appropriate to adopt a predominantly utilitarian approach to decisions regarding waitlisting?

Rather than comparing Indigenous and non Indigenous transplant outcomes, it would appear

fairer to compare the risks and benefits of transplant versus remaining on dialysis for

Indigenous patients.

National coordination to improve outcomes for Indigenous kidney transplant

recipients (involving shared approaches to data collection, immunosuppression, monitoring

and infection prophylaxis for the small number currently transplanted) has been suggested by

us as a stepping stone to improved access to the waiting list, but has proven challenging to

implement. The Australian transplant community has been capable of achieving incremental

but ultimately large improvements in outcome over the last 45 years. Without targeted

efforts, Australians will continue to experience 2 tiers of ESKD treatment outcomes: among

the best in the world for non Indigenous patients, and something substantially less than that

for Indigenous Australians.

ACCEPTED

Copyright © Wolters Kluwer Health. Unauthorized reproduction of this article is prohibited.

5

References

1. Alexander SI, Clayton PA, Chadban SJ. Organ transplantation in Australia.

Transplantation. 2017; 101(5):891-2.

2. Australia & New Zealand Dialysis & Transplant Registry. The 39th

Annual ANZDATA

Report. http://www.anzdata.org.au/v1/report_2016.html. Updated January 30, 2017.

3. Yeates KE, Cass A, Sequist TD, et al. Indigenous people in Australia, Canada, New

Zealand and the United States are less likely to receive renal transplantation. Kidney Int.

2009; 76(6):659-64.

4. Anderson K, Devitt J, Cunningham J, Preece C, Jardine M, Cass A. If you can't comply

with dialysis, how do you expect me to trust you with transplantation? Australian

nephrologists' views on Indigenous Australians' 'non-compliance' and their suitability for

kidney transplantation. Int J Equity Health. 2012; 11(21):1-14.

5. Barraclough KA, Grace BS, Lawton P, McDonald SP. Residential location and kidney

transplant outcomes in Indigenous compared with non-Indigenous Australians.

Transplantation. 2016; 100(10):2168-76.

ACCEPTED