Center, socioeconomic deprivation linked with worse childhood liver transplant outcomes

The socioeconomic deprivation of a child’s neighborhood was associated with worse adverse long-term outcomes after liver transplantation, according to research presented at The Liver Meeting Digital Experience.

However, Sharad Wadhwani, MD, MPH, assistant professor, pediatrics, at the University of California, San Francisco School of Medicine, and colleagues found that center-specific practice can mitigate those effects.

“Given that our previous work found that children from socioeconomically deprived neighborhoods had increased risk for graft failure and death, we wanted to better understand the role of the transplant center,” Wadhwani said in a press release. “Specifically, we were interested in learning whether certain centers who care for predominately socioeconomically deprived children are able to attain excellent outcomes while also primarily serving these particularly vulnerable children. If there were such centers, then we could learn from them and apply these learnings in other transplant centers with the hopes of realizing more equitable outcomes.”

Researchers analyzed data from a scientific registry of transplant recipients from 2008 to 2013. They matched patients aged younger than 18 years to a validated socioeconomic deprivation index based on their home ZIP code.

The deprivation index included neighborhood characteristics, including the percentage of households below the poverty line, median household income and the fraction of the population with no health insurance.

Investigators categorized centers as either “high” or “low” patient-mix deprivation based on whether the deprivation index was above or below the median patient-mix deprivation index of the cohort, respectively. They also grouped centers as either “high” or “low” performing based on their 10-year graft survival rates compared with the rates of the overall cohort.

Among 2,474 patients, the mean deprivation index was 0.38±0.12, and the overall 10-year graft survival was 78%.

In their analysis, Wadhwani and colleagues found that each 0.1-unit increase in center deprivation was associated with increased hazard for graft loss (HR = 1.28; 95% CI, 0.99-1.65). They also identified liver disease etiology (percentage of patients with “other”; HR = 1.13; 95% CI, 1.02-1.26) and median laboratory MELD/PELD score at transplant (HR =1.04; 95% CI, 1-1.08) as center-level characteristics associated with graft loss.

Center deprivation remained associated with graft loss after adjusting for center-level covariables, including liver disease etiology and status 1A/1B at transplantation time. However, after researchers stratified centers based on performance status, the effect of deprivation was no longer significant.

“This study uncovers significant center-to-center variability with regards to long-term outcomes for children undergoing liver transplantation. Importantly, we found that there are certain centers caring for children from predominantly high-deprivation neighborhoods who realize excellent post-transplant outcomes,” Wadhwani said in the release. “These data demand that we learn from these centers to uncover the center-specific practices that might contribute to these equitable outcomes. Furthermore, regulatory agencies such as UNOS should benchmark and report long-term outcomes and socioeconomic inequities in outcomes by center to further incentivize equitable care for these particularly vulnerable children.”