Background <p>Australia’s diverse geography and climate conditions may influence the substantial burden of kidney failure. Understanding current climate impacts on kidney health is critical amid ongoing climate change. This study examines geographical variations and associations with climate conditions in kidney failure incidence among patients initiating kidney replacement therapy (KRT).</p> Methods <p>Data were sourced from the Australian and New Zealand Dialysis and Transplant Registry, the Bureau of Meteorology, and the Australian Bureau of Statistics. Climate conditions, remoteness, socioeconomic index, age, BMI, ethnicity, and state of residence were analysed using a spatial Bayesian regression model to estimate their effects on kidney failure incidence among patients initiating KRT.</p> Results <p>Among 49,363 patients, 61.5% were male, 74.3% were Caucasian, and 40.5% were former smokers. Kidney failure patients receiving KRT are clustered across Australia (Moran’s <i>I</i> = 0.38). The incidence rate of kidney failure patients receiving KRT was high in the “hot dry summer, warm winter” (714.2 per 100,000) and “hot humid summer, warm winter” (607.1 per 100,000) climate zones. The risk was high in “hot humid summer, warm winter” (relative risk [RR] = 1.70, 95% credible interval [CI]: 1.30–2.21) compared to “mild to warm summer, cold winter” zone. The risk was attenuated after adjusting for geographical and demographic covariates. Very remote areas had a threefold risk compared to major cities (RR = 3.00, 95% CI: 2.43–3.71).</p> Conclusions <p>This study revealed substantial regional variations in kidney failure incidence among patients initiating KRT, related to differences in climate conditions, notably hot, humid environments. These incidence patterns also accounted for factors including remoteness, socioeconomic status, and state of residence, highlighting the need to address climate-related health disparities in the context of ongoing climate change.</p>