Neighborhood Deprivation Linked to Medication Level Variability in Liver Transplant Recipients

Neighborhood deprivation is associated with adverse outcomes post-liver transplantation in pediatric recipients. We examined the association between neighborhood deprivation index (NDI) and medication level variability index (MLVI), T-cell mediated rejection (TCMR), and graft failure/death in adult liver transplant recipients.

We conducted a retrospective cohort study of 1485 adult liver-transplant recipients with >1 year follow-up. NDI was calculated at the census tract level. MLVI, the standard deviation of ≥3 sequential tacrolimus troughs, was dichotomized at MLVI > 2. Hospitalization was analyzed as a binary variable.

The median age was 65, and 36% were female. In multivariate regression, increased NDI was associated with 20% increased odds of MLVI > 2 between 1-3 years post-transplant (95% CI 1.1-1.3) but not MLVI > 2 between 3-5 years. NDI was associated with a 2.2 times higher hazard of hospitalization between 1-3 years post-transplant (95% CI 1.1-4.4); but not between 3-5 years (HR 1.9, 95% CI 1.0-3.7). NDI was not significantly associated with increased hazard of rejection or graft failure/death. Adjusting for NDI, MLVI > 2 between 1-3 and 3-5 years was associated with a 30% higher hazard of rejection (95% CI 1.1-1.6), and between 1-3 years, a 40% increased hazard of graft failure/death (95% CI 1.2-1.5). We found geospatial hotspots of rejection with positive autocorrelation at Years 1-3 and 3-5 post-transplant (Geary's C 0.97, p = 0.01).

Efforts to understand why individuals from disadvantaged neighborhoods experience poorer immunosuppression adherence may uncover targeted strategies to improve medication adherence for high-risk groups.