At Europe's migration crossroads: dialysis outcomes and transplant access in patients immigrating to Belgium

Global inequities in dialysis and kidney transplantation among immigrant populations remain poorly characterized. At the crossroads of European migration, Brussels' Brugmann University Hospital provides an opportunity to examine outcomes in one of the most ethnically diverse dialysis cohorts in Western Europe, including a substantial proportion of undocumented immigrants.

We conducted a retrospective 15-year analysis of 497 incident dialysis patients (2010-2024), categorized as Western European (WE, 32%), Eastern European (EE, 21%), North African (NA, 26%), or Sub-Saharan African (SSA, 21%). Kaplan-Meier and Cox models assessed survival, while Fine-Gray competing-risk analyses evaluated transplant access.

Despite language barriers, housing instability, and the frequent lack of legal residency, equitable dialysis delivery was achieved, with peritoneal dialysis implemented in 25%-30% of patients, including asylum seekers and undocumented immigrants. Median pre-dialysis nephrology follow-up was longer in WE (8 months) than in other groups (<1 month). Age (HR = 1.73) and comorbidity (HR = 1.62) independently predicted mortality, whereas ethnicity (HR = 0.77) reflected demographic rather than systemic disparities. Competing-risk analysis showed the highest transplant access among SSA patients (35%-40% at 10 years; sub-distribution hazard ratios) = 2.13, P = .004), confirming that allocation was driven by clinical suitability rather than origin.

In this uniquely multicultural setting, equitable access to dialysis and transplantation can be achieved across all immigrant groups, even among undocumented patients, but only when a dedicated hospital, social, and administrative structure is deliberately built to make it possible. The success of peritoneal dialysis among asylum seekers and the high transplant rates in SSA patients reflect an integrated system where equity is actively implemented, not assumed. These findings demonstrate that outcomes depend on clinical and organizational excellence rather than geography or migration status, offering a model for inclusive nephrology care in increasingly diverse European societies.