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

Nineteen nephrologists, from eight renal units treating the majority of Indigenous Australian renal patients, were interviewed in 2005-06 as part of a larger study. Thematic analysis was undertaken to investigate how compliance factors in specialists' decision-making, and its implications for Indigenous patients' likelihood of obtaining transplants.Specialists commonly identified Indigenous patients as both non-compliers and high-risk transplant candidates. Definition and assessment of 'compliance' was neither formal nor systematic. There was uncertainty about the value of compliance status in predicting post-transplant outcomes and the issue of organ scarcity permeated participants' responses. Overall, there was marked variation in how specialists weighed perceptions of compliance and risk in their decision-making.Reliance on notions of patient 'compliance' in decision-making for transplant referral is likely to result in continuing disadvantage for Indigenous Australian ESKD patients. In the absence of robust evidence on predictors of post-transplant outcomes, referral decision-making processes require attention and debate.End-stage kidney disease (ESKD) affects Indigenous Australians disproportionately [1]. Transplantation is the optimal treatment [2], but there is a substantial and persistent disparity in transplants given to Indigenous and non-Indigenous patients [3]. The vast majority of Indigenous Australians with ESKD remain on life-long dialysis. Their lower probability of receiving a transplant is not fully explained by measurable clinical differences.Many Indigenous Australians share contextual factors that may detrimentally affect their engagement with the health system and their response to the significant personal demands imposed by dialysis regimens. As a group, they have higher levels of socioeconomic disadvantage, lower educational attainment and poorer health literacy [4]. Many Indigenous dialysis patients experience isolation and reduced engagemen