BARRIERS IN ACCESS TO LIVER TRANSPLANTATION FOR ETHNIC MINORITY CHILDREN IN THE UNITED STATES DO NOT TRANSLATE INTO INFERIOR OUTCOMES

Abstract

Purpose: Disparities in children undergoing liver transplantation (LT) exist and have been attributed to a combination of racial and socioeconomic circumstances. We sought to evaluate the influence of those barriers in access to LT on graft and patient survival. Methodology: We evaluated data from the U.S. Scientific Registry of Transplant Recipients (SRTR) of all pediatric (<18 years old) LT recipients from 1999 to 2014 and compared outcomes by race or ethnicity: Hispanic, non-Hispanic White (NHW), and non-Hispanic Blacks (NHB). We assessed 1- and 5-year patient survival (PS) and death-censored graft survival (DCGS). Characteristics controlled for included: living or deceased donor, brain- or cardiac-death donor (DCD), graft type (whole, partial, split), recipient age, BMI, primary disease, PELD score, re-transplant status, graft rejection, functional status, and cold ischemia time (CIT). Cox regression analysis was used with an alpha level of 0.05. Results: During the 15-year period, 8,331 (4,876 NHW, 1,522 NHB, and 1,933 Hispanic) pediatric LT procedures were performed in the U.S. Hispanic children were listed and transplanted at a significantly younger age (4.4, 4.8, respectively) than NHW (5.2, 5.6; p<0.001) and NHB children (5.1, 5.5; p<0.001). Compared to NHW (15.3%) and NHB (20.3%), there was a greater proportion of Hispanic children requiring total functional assistance (23.7%; p<0.001) at LT. Additionally, NHB and Hispanic children had exception points approved with lower frequency than NHW (p=0.036). Compared to NHW (14.2%), NHB (7.5%) and Hispanic (11.5%) children were less likely to have a living donor (p<0.001). NHB were more likely to receive a whole deceased donor graft (69.4%) than NHW or Hispanic children (63.4% and 59.6%, respectively; p<0.001). However, Hispanic children were more likely to receive a split deceased donor graft (19.8% for Hispanics, 12.9% for NHW, 14.7% for NHB; p<0.001). Listing PELD was higher for Hispanics (21.1±11.3) and NHB (20.4±10.7), compared to NHW (20.0±10.8; p=0.023). One-year PS for NHW, NHB, and Hispanics was 82.9%, 83.2%, and 83.1%, respectively; one-year DCGS was 82.8%, 83.1%, and 83.0%, respectively. Five-year PS for NHW, NHB, and Hispanics was 60.6%, 58.5%, and 57.9%, respectively; five-year DCGS was 60.6%, 58.5%, and 57.9%, respectively. None of these was significantly different in any two-way comparison.Multivariate analysis of one-year graft loss showed that older recipient age (HR 0.962, 95% CI 0.943-0.982) was protective while re-transplant status (1.554, 1.180-2.048) and the need for functional assistance (3.079, 2.307-4.109) were predictive of graft loss. Conclusion: Barriers exist for minority children to navigate the LT listing process. However, once transplanted, Hispanic and NHB children outcomes are comparable to NHW. Further research is necessary to understand and ease barriers in accessing LT for minority children.