Table 1.

Summary of Findings of Included Studies.

Study	Population of interest	Study design	Literature type	Data source	Key findings
Anderson et al32	Indigenous patients with ESKD	Qualitative	Peer-Reviewed Research Article	Nephrology health care professionals across Canada	Remote living location poses difficulties in providing and accessing care. Low socioeconomic status and inadequate health system resourcing further disadvantages Indigenous patients in accessing KT.
Canadian Council for Donation and Transplantation33	Indigenous peoples in Canada	Cross-sectional	Data Report	Sample of Canadian residents	Indigenous participants were less likely than non-Indigenous participants to reject the statement “the organ and tissue donation process could exploit people of colour, First Nations people or other minority groups”
Canadian Council for Donation and Transplantation33	Indigenous community	Qualitative	Data Report	Indigenous communities in Winnipeg and Saskatoon	Common knowledge of organ donation, support of prevention vs transplant. Power of educating each other through sharing personal experiences in transplant. Importance of ceremony, elder support, and storytelling in decision-making. Giving and receiving as part of the freedom of life. Conflict between traditional beliefs and benefits of donation (eg, passing on culture). Importance of knowing about the donor/recipient in feeling comfort about the organ donated/received may stem from experiences of racism. Attitudes and beliefs about organ donation are sacred, personal decisions often formed within families and communities, especially with elders. Resistance to Western medicine due to colonialism.
Canadian Institute for Health Information1	Indigenous patients with ESKD	Retrospective	Data Report	Canadian Organ Replacement Register	Between 2002 and 2011, Indigenous peoples in Canada were 3 times as likely to be new patients receiving treatment for ESKD or to be receiving treatment than non-Indigenous peoples. Indigenous patients were less likely than non-Indigenous patients to receive KT (27% vs 42%, respectively).
Can-SOLVE CKD Network34	Indigenous community	N/A	Project Summary	Unspecified	In Saskatchewan, Indigenous patients represent 16% of the province’s population but make up half of the patients on dialysis. It is understood that the lack of cultural adaptation and translation of existing educational tools on ESKD treatment options may prevent patients from being able to make informed decisions about ESKD treatment options.
Davison and Jhangri35	Indigenous community	Mixed-Methods	Peer-Reviewed Research Article	Indigenous communities in Alberta	Less than half of participants reported willingness to donate organs or those of loved ones after death. Reasons not to donate included belief that dead should be left in peace and need to enter spiritual world with an intact body. Support for organ donation prioritized value of life and needs of community. Traditional beliefs seen as supportive of organ donation, with living donation able to benefit community directly.
Dyck and Tan36	Indigenous patients with ESKD	Retrospective	Peer-Reviewed Research Article	Canadian Organ Replacement Register	In Saskatchewan, nondiabetic Indigenous patients with ESKD were almost as likely as their non-Indigenous counterparts to receive KT. Diabetic Indigenous patients with ESKD were half as likely as their non-Indigenous counterparts to receive KT.
Gill37	Communities marginalized by ethnicity	N/A	Conference Presentation	Unspecified	Cultural or religious objections to donation, mistrust, and a lack of understanding of the donation process may result in disparate access to KT for communities marginalized by ethnicity.
Government of Alberta38	Indigenous organ transplant recipients	Retrospective	Data Report	Alberta First Nations Information Governance Center	In Alberta between 2006 and 2017, out of the average of 307 transplants conducted in the province per year, 12 were on Indigenous patients. Approximately 60% of transplants received by Indigenous patients were kidney transplants in comparison to 45% for non-Indigenous patients.
Matsuda-Abedini et al39	Indigenous pediatric KT recipients	Retrospective Cohort	Peer-Reviewed Research Article	BC Children’s Hospital	Lower rates of preemptive KT in Indigenous pediatric patients.
Mollins40	Indigenous KT recipients	Qualitative	Thesis	KT recipients in Manitoba	Reluctance to accept living donation because of a concern that the donor’s remaining kidney would become diseased and they would eventually develop CKD. Challenges in obtaining transportation to urban and local health care centers for treatment. Fearing kidney graft rejection interfered with patients’ freedom to return home (due to lack of specialized medical support in remote northern communities), find employment, and make a life for their family posttransplant. The need to be under constant medical supervision posttransplant noted as a disadvantage of the process, but a “small price to pay.”
Molzahn et al41	Indigenous community	Qualitative	Peer-Reviewed Research Article	Coast Salish community in British Columbia	General lack of knowledge of organ donation system in BC, not commonly discussed in community. Fatalistic beliefs and need for intact body to continue spiritual journey against transplant intervention, and organ donation seen to interfere with death rituals. Organ donation thought to potentially cause transfer of spirit to recipient. Greater comfort in donating to known recipient. Generational differences in attitudes toward donation. Context of frustration with administration of health care services to Indigenous communities, experiences of racism in health care, distrust in health care system leads to unease/fear about going through organ donation.
Ontario Renal Network (2020)	Indigenous patients with CKD	N/A	Webpage	Unspecified	Experiences of poverty, significant travel times to receive treatment, and limited access to health care services are challenges for Indigenous patients with CKD in Ontario in accessing appropriate treatment.
Promislow et al42	Indigenous KT recipients	Retrospective Cohort	Peer-Reviewed Research Article	Canadian Organ Replacement Register	Likelihood of KT for Indigenous patients age 18-40 was half that of whites. Likelihood of KT for Indigenous patients age 51-60 was 35% less than whites, and no significant difference for patients >60. Likelihood of LDKT in Indigenous patients age 18-40 was 68% less than whites, Indigenous patients age 41-50 was 70% less than whites; Indigenous patients age 51-60 was 56% less, and same for patients >60.
Samuel et al43	Indigenous pediatric patients with ESKD	Observational Cohort	Peer-Reviewed Research Article	Canadian Pediatric ESRD Database	Indigenous pediatric patients experience longer time from start of RRT to first KT than white pediatric patients. Indigenous patient were 64% less likely to receive LDKT and 38% less likely to receive DDKT than white patients with the same time elapsed since start of dialysis. Patients living more than 150 km from pediatric renal care center were less likely than those living closer to receive KT.
Schaubel et al44	ACB, East Asian, South Asian, and Indigenous KT recipients	Retrospective	Peer-Reviewed Research Article	Canadian Organ Replacement Register	Sex disparities in KT access in Canada more pronounced for black, South Asian, and Indigenous patients and less pronounced for white and East Asian patients. White and East Asian men are 18 and 23% more likely to receive KT than women, and black, South Asian, and Indigenous men are 66%, 67%, and 42% more likely to receive KT than women.
Schulz45	Indigenous caregivers of children with ESKD	Qualitative	Thesis	Indigenous caregivers	Challenges in receiving KT included adapting to a new community and being uprooted from familiar surroundings and support networks upon relocation to an urban center to receive KT and financial challenges of living off-reserve.
Smith46	Indigenous living kidney donor	Autoethnography	Peer-Reviewed Research Article	N/A	Experience as health care provider helped in navigating transplant system. Smudges and healing circles used to relieve stress, gain sense of community support, and prepare donor for transplant. Familial experience with ESKD as disincentive to pursuing dialysis. Feeling of dread associated with sterile, cold, medicalized environment. Remote living made journey to dialysis center difficult, but relocation posed challenges in work and being away from community. Financial strain created by difficulties in obtaining reimbursement for expenses of appointments and convalescence posttransplant through FNHIB.
Tonelli et al47	Indigenous patients with ESKD	Cross-sectional	Peer-Reviewed Research Article	Patients on hemodialysis in Alberta	Adjusted likelihood of referral for KT assessment did not differ between Indigenous and non-Indigenous patients on dialysis, no difference in time on dialysis to referral, rate of preemptive referral, or transplant eligibility. Indigenous patients referred for transplant less likely to be active on waitlist than non-Indigenous patients, with longer times from dialysis start to waitlisting. Indigenous patients half as likely as non-Indigenous patients to be waitlisted.
Tonelli et al48	Indigenous patients with ESKD	Retrospective Cohort	Peer-Reviewed Research Article	Canadian Organ Replacement Register	Adjusted likelihood of DDKT and LDKT lower amongst Indigenous patients than white patients. Adjustment for residence location did not significantly influence likelihood of DDKT or LDKT for Indigenous patients.
Tonelli et al49	Indigenous patients with ESKD	Retrospective Cohort	Peer-Reviewed Research Article	Canadian Organ Replacement Register	Indigenous race associated with lower likelihood of KT compared with white patients.
Vescera50	Indigenous patients with ESKD	N/A	News Article	Informal audit	In Saskatchewan, Indigenous patients comprise 16% of the provincial population but make up 50% of the patients with kidney disease and only 15% of those who receive KT. Beliefs among traditional knowledge people around the need to have a whole body to enter the spirit world may hamper interest in organ donation among Indigenous peoples.
Wardmann51	Indigenous patients with ESKD	N/A	Conference Presentation	Unspecified	Indigenous patients have rates of ESKD that are 3.5 times higher than non-Indigenous patients. Indigenous patients with ESKD are less likely to be placed on the KT waiting list, more likely to wait longer for KT, and less likely to receive KT than non-Indigenous patients.
Yeates et al52	Indigenous KT recipients	Retrospective Cohort	Peer-Reviewed Research Article	Canadian Organ Replacement Register	Indigenous patients had lower crude KT rates than white patients, although the proportion of LDKT was slightly higher for Indigenous than white recipients in Canada. Lower adjusted DDKT and LDKT rates in Indigenous patients. Longer DDKT and LDKT wait time for Indigenous than white patients.
Yeates et al12	ACB, East Asian, South Asian, and Indigenous patients with ESKD	Retrospective Cohort	Peer-Reviewed Research Article	Canadian Organ Replacement Register	Indigenous patients had lower adjusted LDKT rates compared with white patients, with disparity worsening over time.
Yoshida et al53	ACB, East Asian, South Asian, and Indigenous KT recipients	Retrospective	Peer-Reviewed Research Article	BC Transplant Database	Caucasians represented 65% of total KT recipients and Indigenous patients represented 4.1% of total KT recipients in the province. KT recipients exhibited the most racial heterogeneity compared with other organ transplant groups.

Note. ESKD = end-stage kidney disease; ESRD = end-stage renal disease; KT = kidney transplantation; CKD = chronic kidney disease; LDKT = living donor kidney transplantation; DDKT = deceased donor kidney transplantation; ACB = African, Caribbean, and Black; RRT = renal replacement therapy; FNHIB = First Nations and Inuit Health Branch.