Neighborhood Socioeconomic Deprivation Is Associated With Worse Patient and Graft Survival Following Pediatric Liver Transplantation

Sharad I. Wadhwani; Andrew F. Beck; John Bucuvalas; Laura Gottlieb; Uma Kotagal; Jennifer C. Lai


American Journal of Transplantation. 2020;20(6):1597-1605. 

In This Article

Abstract and Introduction


Long-term outcomes remain suboptimal following pediatric liver transplantation; only one third of children have normal biochemical liver function without immunosuppressant comorbidities 10 years posttransplant. We examined the association between an index of neighborhood socioeconomic deprivation with graft and patient survival using the Scientific Registry of Transplant Recipients. We included children <19 years who underwent liver transplantation between January 1, 2008 to December 31, 2013 (n = 2868). Primary exposure was a neighborhood socioeconomic deprivation index—linked via patient home ZIP code—with a range of 0–1 (values nearing 1 indicate neighborhoods with greater socioeconomic deprivation). Primary outcome measures were graft failure and death, censored at 10 years posttransplant. We modeled survival using Cox proportional hazards. In univariable analysis, each 0.1 increase in the deprivation index was associated with a 14.3% (95% confidence interval [CI]): 3.8%-25.8%) increased hazard of graft failure and a 12.5% (95% CI: 2.5%-23.6%) increased hazard of death. In multivariable analysis adjusted for race, each 0.1 increase in the deprivation index was associated with a 11.5% (95% CI: 1.6%-23.9%) increased hazard of graft failure and a 9.6% (95% CI: −0.04% to 20.7%) increased hazard of death. Children from high deprivation neighborhoods have diminished graft and patient survival following liver transplantation. Greater attention to neighborhood context may result in improved outcomes for children following liver transplantation.


Although 1-year survival following pediatric liver transplantation hovers at 90%,[1] at 10 years, only one third of children have the ideal outcome, defined as allograft health as estimated by normal serum alanine aminotransferase and γ-glutamyltransferase levels in the absence of comorbidities related to immunosuppression.[2,3] Even this estimate is optimistic since 50% of pediatric liver recipients have evidence of structural allograft injury in the face of normal liver tests.[4] While immune- and nonimmune-mediated allograft injury and complications from immunosuppression play a central role, ineffective self-management increases risk for nonadherence and graft injury.[2,4–7] Social determinants of health, including neighborhood context, influence self-management capabilities in children with chronic conditions and are key contributors to health outcomes but have not been routinely collected by transplant registries[8] or implicated directly in liver transplant outcomes.[5,9–11] While transplant registries collect insurance status, this metric does not accurately reflect one's socioeconomic status (SES)—especially in the Affordable Care Act era where increasing percentages of children are covered by Medicaid.[12] Moreover, public insurance coverage is particularly high among children with complex chronic diseases, such as those requiring transplantation, further complicating its use as an SES proxy.[13,14]

Neighborhood-level socioeconomic data (linked via home ZIP code) provide information that can contextualize a child's living environment, including the extent of neighborhood socioeconomic resources. These data might provide a more comprehensive understanding of the socioeconomic milieu in which a patient experiences and manages his or her chronic disease.[9] Such geographic, place-based data are associated with adverse health outcomes across diseases,[2,3] and this knowledge has been used to improve other medical outcomes for children of low SES.[10,15–20] Using a validated index of neighborhood socioeconomic deprivation in a cohort of pediatric liver transplant recipients, we previously demonstrated that children from the most deprived neighborhoods have twice the rates of nonadherence.[21] This index, available for every US census tract and ZIP code, incorporates 6 measures of neighborhood SES from the US Census Bureau/American Community Survey. Yet, gaps in knowledge remain as to how graft and patient survival outcomes more broadly differ by neighborhood characteristics. In this study, we examined the association between this same neighborhood deprivation index and long-term graft and patient survival in pediatric liver transplant recipients. We hypothesized that higher levels of neighborhood socioeconomic deprivation would be associated with a higher risk of graft loss and mortality.