Socioeconomic Disadvantage and Race/Ethnicity Are Associated with Mortality After Pediatric Heart Transplantation

Abstract

<h3>Purpose</h3> Determine the association of socioeconomic disadvantage (SED) and race/ethnicity with post-heart transplant (HTx) outcomes in children. <h3>Methods</h3> A retrospective single-center cohort study of patients < 18 years of age who underwent HTx between 1/2006-12/2020 was performed. The Area Deprivation Index (ADI), a validated census-based neighborhood deprivation tool (higher value = more disadvantaged) that incorporates income, education, employment, and housing quality, was used to determine SED status. Patients were divided into less disadvantaged ("no SED"; ADI < 25%-ile) and more disadvantaged ("SED"; ADI > 25%-ile) as previously described. Outcomes included post-HTx survival (Kaplan-Meier curves and cox-proportional regression) and rejection (total episodes per year of follow-up were compared using linear regression). <h3>Results</h3> The cohort included 290 HTx (median age 5 yr [IQR 1- 13 yr], median weight 16kg [IQR 8 - 43 kg]). Median follow-up time from HTx was 4.3 yr (IQR: 1.7 - 7.3 yr). The cohort was 40% Hispanic, 33% Non-Hispanic White (NHW), 20% Non-Hispanic Black (NHB) and 7% Other. Median ADI was 63 (IQR: 43 - 83). Patients with SED had a significantly greater risk of death (HR: 4.2, 95% CI: 1.01 - 17.3) compared to those with no SED; Fig 1A. After adjusting for ADI, patients identifying as NHB (HR: 2.2, 95% CI: 1.03 - 4.6) and Other (HR: 3.8, 95% CI: 1.4 - 10.2) had a significantly higher risk of death compared to NHW (Fig 1B). Compared to NHW, only "Other" had an increased frequency of rejection (p = 0.01). Patients with SED did not have more episodes of rejection per year of follow up (0.21 vs 0.18; p = 0.8). <h3>Conclusion</h3> Socioeconomic disadvantage and race/ethnicity (independent of ADI) are associated with worse post-HTx survival. Socioeconomic disadvantage was not associated with frequency of rejection; neither was NHB norHispanic race/ethnicity. Identifying and addressing any potentially modifiable determinants of SED is imperative to improve survival after pediatric HTx.