Cultural Diversity and Kidney Replacement Therapy Outcomes in Australia

Introduction: Australia's population is culturally and linguistically diverse (CALD), with 31% of Australians born overseas and 22% speaking a language other than English at home. However, there is limited evidence on how CALD backgrounds influence access to kidney replacement therapy (KRT) and outcomes. We examined patient characteristics, treatment modality, waitlisting, and outcomes across CALD groups. Methods: We analyzed the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry data for non-Indigenous adults who initiated KRT in Australia (2002–2023). Patients were grouped by place of birth: Australia or New Zealand (Aus/NZ), other English-speaking countries (CALD-English), and non-English-speaking countries (CALD-non-English). Competing risk and multinomial logistic regression was used to assess associations between CALD status and KRT modality, waitlisting, mortality, and dialysis withdrawal. Results: Among 72,621 KRT initiations, 52,045 non-Indigenous adults who commenced KRT in Australia met the inclusion criteria. Of these, 285 (0.5%) had missing country-of-birth data, leaving 51,760 patients for grouping (63.8% Aus/NZ-born, 6.5% CALD-English, and 29.7% CALD-non-English). CALD-non-English were less likely to commence home hemodialysis (HD) (relative risk ratio [RRR]: 0.71, 95% confidence interval [CI]: 0.58–0.88) or receive preemptive transplantation (RRR: 0.38, 0.33–0.44) but more likely to start peritoneal dialysis (PD) (RRR: 1.35, 1.29–1.42) than Aus/NZ. After adjustment, CALD-non-English had higher waitlisting (subdistribution hazard ratio [SHR]: 1.34, 1.28–1.40), lower mortality (SHR: 0.76, 0.74–0.78), and lower dialysis withdrawal (RRR: 0.54, 0.51–0.57) than Aus/NZ. Conclusion: CALD status was independently associated with KRT modality, transplant waitlisting, survival, and dialysis withdrawal. Understanding how cultural values, health literacy, and family involvement shape KRT decisions and outcomes is essential for designing equitable, culturally sensitive kidney care.