While the rates of renal replacement therapy for end-stage renal disease (ESRD) among Aboriginal Australians have increased rapidly over the past 20 years, the chances of Aboriginal Australians receiving a kidney transplant are about one-third those among non-Aboriginal Australians. The lower percentage of transplants from living donors for Aboriginal recipients (14%) compared with non-Aboriginal Australians (36%) since 1997 contributes to this. Furthermore, among recipients of grafts from cadaveric donors, waiting times are longer, the number of human leucocyte antigen mismatches is significantly greater among Aboriginal (4.11 (95% confidence interval 3.83-4.39)) vs non-Aboriginal recipients (2.95 (95% CI 2.87-3.02); P <0.001), and sensitised recipients are more common (peak panel reactive antibody > or = 50%, 25% among Aboriginal vs 12% among non-Aboriginal recipients (P <0.001). Graft survival is poorer amongst Aboriginal Australians than non-Aboriginal Australians - independent of whether the graft is from a living donor or deceased donor. Among primary deceased donor graft recipients, the hazard ratio (HR) for graft survival among Aboriginal recipients was 3.1 (95% CI 2.2-4.2), P <0.001 and that for patient survival 3.6 (95% CI 2.5-5.1, P <0.001) compared with non-Aboriginal Australians. This higher graft-loss rate among Aboriginal recipients of primary deceased donor grafts persists even after adjustment for the higher rate of comorbidity in this group (HR of 1.95 (1.22-3.11, P=0.005). This is reflected in higher rates of vascular rejection among Aboriginal recipients, with a crude relative risk of 1.97 (95% CI 1.63-2.34) (P <0.001), compared with non-Aboriginal Australians. Despite the advantages in terms of morbidity and quality of life, it remains uncertain whether transplantation offers a mortality advantage among Aboriginal Australians.