Socioeconomic disparities in long-term outcomes after pediatric liver transplantation in a universal health care
Toshifumi Yodoshi1, M Ellen Kuenzig2, Furong Tang3
1Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology, Pancreatology, and Nutrition, Stead Family Children's Hospital, Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA; Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Insights
Pediatric liver transplant (LT) recipients face higher risks of mood disorders and cancer. However, LT does not prevent future childbirth, and addressing socioeconomic factors is crucial for improving long-term outcomes.
Area of Science:
- Pediatric Hepatology
- Transplantation Medicine
- Public Health
Background:
- Pediatric liver transplantation (LT) is a life-saving procedure.
- Long-term outcomes and survivorship burden in pediatric LT recipients are not fully understood.
- The impact of socioeconomic status (SES) on post-transplant outcomes requires investigation.
Purpose of the Study:
- To quantify the survivorship burden in pediatric LT recipients compared to general population controls.
- To assess the influence of socioeconomic status (SES) on long-term outcomes after pediatric LT.
- To analyze specific outcomes including mortality, chronic conditions, de novo cancers, and live births.
Main Methods:
- Population-based cohort study in Ontario, Canada (1991-2021).
- Linked pediatric LT recipients (n=449) with provincial administrative data.
- Matched 1:5 with general-population controls (n=2,245) on sex and birth year; analyzed mortality, chronic conditions, cancers, and live births, with SES interaction analyses.
Main Results:
- 20-year survival for LT recipients was 78%.
- At 10 years, LT recipients had higher incidence of mood disorders (IRR 3.61) and de novo cancers (IRR 25.1), with cancers concentrated in the first 5 years.
- Lower neighborhood income predicted higher post-LT mortality (aHR 2.1), indicating SES disparities.
Conclusions:
- Pediatric LT recipients experience significant long-term survivorship burdens, including increased risks for mood disorders and de novo cancers.
- Childhood LT does not preclude later family-building, as live-birth incidence was similar in female recipients and controls.
- Despite universal healthcare, socioeconomic disadvantage is linked to worse long-term outcomes, highlighting the need to integrate social determinants of health into survivorship care.
Abstract:
We conducted a population-based cohort study of pediatric liver transplantation (LT) in Ontario, Canada, a universal health care setting, to quantify survivorship burden relative to matched general-population controls and assess whether socioeconomic status modified these differences. First, isolated pediatric LTs (1991-2021) were linked to provincial administrative data and matched 1:5 on sex and birth year to general-population controls. Outcomes were mortality, chronic conditions, de novo cancers, and live births, with prespecified socioeconomic status interaction analyses. Among 449 LT recipients and 2245 controls (median age, 1.9 years), 20-year survival was 78%. At 10 years, LT recipients had a higher cumulative incidence of mood disorders (16.1% vs 8.77%; incidence rate ratio [IRR], 3.61; 95% confidence interval [CI], 2.9-4.5) and de novo cancer (7.83% vs 0.19%; IRR, 25.1; 95% CI, 12.1-52.0), with cancer excess concentrated in the first 5 years. In a female-only landmark analysis beginning at age 15 years, live-birth incidence was similar between groups (IRR, 0.75; 95% CI, 0.39-1.44), suggesting childhood LT does not necessarily preclude later family-building. Lower neighborhood income predicted higher post-LT mortality (adjusted hazard ratio, 2.1; 95% CI, 1.2-3.7). Despite universal health care, socioeconomic disadvantage was associated with worse long-term outcomes; integrating social determinants of health into survivorship care is needed.
