Disparities in Waitlist and Posttransplantation Outcomes in Liver Transplant Registrants and Recipients Aged 18 to 24 Years

Abstract

Background We evaluated liver transplantation waitlist and posttransplantation outcomes in 18–24 year olds compared to both younger (0–17 year old) and older (25–34 year old) registrants and recipients. Methods Utilizing national data from the United Network for Organ Sharing, competing risk, Cox regression and Kaplan-Meier analyses were performed on first-time liver transplant registrants (n=13,979) and recipients (n=8,718) ages 0–34 years old between 2002 to 2015. Results Among nonStatus 1A registrants, both 0–17 and 25–34 year olds were less likely to experience drop-out from the waiting list compared to 18–24 year olds (adjusted hazard ratio [AHR] 0–5 year olds=0.36, 6–11=0.29, 12–17=0.48, 18–24=1.00, 25–34=0.82). Although there was no difference in risk of graft failure across all age groups, both younger and older age groups had significantly lower risk of posttransplant mortality compared to 18–24 year olds (AHR for 0–5 year olds=0.53, 6–11=0.48, 12–17=0.70, 18–24=1.00, 25–34=0.77). This may be related to lower likelihood of re-transplantation after graft failure in 18–24 year olds. Conclusions This national registry study demonstrates for the first time poorer waitlist and postliver transplant outcomes in young adults ages 18–24 years at the time of listing and transplantation compared to older and younger age groups. Given the potential survival benefit in transplanting young adults and the shortage of solid organs for transplant, future studies are critical to identify and target modifiable risk factors to improve waitlist and long-term posttransplant outcomes in 18–24 year old registrants and recipients.

Impact of Payer Status on Delisting Among Liver Transplant Candidates in the United States

“…Consistent with studies demonstrating the impact of socioeconomic burden on pretransplantation management and referral, ( 8,17‐19 ) we found that higher levels of education and employment were protective against waitlist mortality and clinical deterioration. These findings may be explained in part by greater compliance with medical recommendations, access to care prior to LT, or disease severity.…”

20‐ to 25‐year patient and graft survival following a single pediatric liver transplant—Analysis of the United Network of Organ Sharing database: Where to go from here

“…Our observation of worse patient and graft outcomes in children transplanted at progressively older ages compared to those transplanted at age <5 years is not a new observation. Dharnidharka et al, Ebel et al, and Sagar et al have all noted this same trend of teenagers being most at risk for death and graft loss. This is not entirely unexpected, as transplantation during adolescence has previously been strongly associated with non‐adherence; adolescents are reported to have a rate of immunosuppression non‐adherence twice as high as younger cohorts; moreover, when patients begin self‐managing their condition, non‐adherence may be even greater .…”

“…De novo autoimmune hepatitis and recurrent hepatitis were the only hepatitides reported in our registry report accounting for a total of 29 reports of graft loss in the 2000-2014 era ( Figure 5). 16,20,21 have all noted this same trend of teenagers being most at risk for death and graft loss. This is not entirely unexpected, as transplantation during adolescence has previously been strongly associated with non-adherence 22,23 ; adolescents are reported to have a rate of immunosuppression non-adherence twice as high as younger cohorts; moreover, when patients begin self-managing their condition, non-adherence may be even greater.…”

Impact of active antibody‐mediated rejection treatment on donor‐specific antibodies in pediatric kidney transplant recipients

“…Adolescent and young adult solid organ transplant recipients have the greatest incidence of graft loss among age groups, likely due to poor medication adherence, so frequent DSA monitoring may be necessary for this high-risk group. [34][35][36][37][38][39] There are several limitations to the present study. First, this was a small, single-center, retrospective review without controls.…”

“…DSA monitoring is beneficial for early detection of dnDSA, as well as long‐term follow‐up of AMR treatment efficacy. Adolescent and young adult solid organ transplant recipients have the greatest incidence of graft loss among age groups, likely due to poor medication adherence, so frequent DSA monitoring may be necessary for this high‐risk group …”