Education and Psychosocial Factors Predict Odds of Death After Transfer to Adult health Care in Pediatric Liver Transplant Patients

Abstract

Objectives:To analyze demographic, psychosocial, and clinical factors in pediatric liver transplant recipients for their association with death or loss to follow up in adulthood. We aimed to better understand known health disparities in transplant outcomes and identify potentially modifiable risk factors prior to transfer. Methods: A retrospective cohort study of children who underwent liver transplantation at a large tertiary transplant center and were transferred to adult care between 2000 and 2015.Results: During the study period, 101 qualifying patients were transferred. Ninety-three individuals followed with an adult provider, while 8 were lost to follow up. In total 23 of 93 patients died after transfer (24.7%). Several childhood factors were associated with adult death: Black race [odds ratio (OR) 6.59, P < 0.001]; psychiatric illness or substance use (OR 2.81, P = 0.04); failure to graduate high school before transfer (OR 9.59, P < 0.001); posttransplant tacrolimus medication-level variability index >2.5 (OR 5.36, P = 0.04); provider documentation of medication nonadherence (OR 4.72, P = 0.02); acute cellular rejection (OR 4.44, P = 0.03); the presence of diabetes mellitus (OR 5.71, P = 0.001), and chronic kidney disease (OR 2.82, P = 0.04). Failure to graduate HS was associated with loss to follow up (P < 0.001). On multivariate analysis, Black race, substance use, diabetes, and failure to graduate HS retained association with adult death (each P < 0.05). Conclusions: Complex, intertwined patient characteristics are associated with increased odds of death in pediatric liver transplant recipients transferred to adult care. Early recognition of high-risk patients and intervention for modifiable factors, such as improved HS graduation and substance use prevention, may improve long-term outcomes.

Equity in liver transplantation: are we any closer?

“…Findings demonstrated higher rates of death in Black patients after transfer compared to other races (44% vs. 16%) and experienced about 50% mortality at 20 years post-LT (double that observed in White patients) [26]. They followed this with a retrospective single-center study identifying demographic, psychosocial, education, and clinical factors in pediatric LT patients that may be predictive of future death or loss to follow-up in adulthood [27]. Findings demonstrated that adult death was persistently associated with Black race (odds ratio, OR 6.59), substance use (2.81), and failure to graduate high school (OR 9.59) [27].…”

“…They followed this with a retrospective single-center study identifying demographic, psychosocial, education, and clinical factors in pediatric LT patients that may be predictive of future death or loss to follow-up in adulthood [27]. Findings demonstrated that adult death was persistently associated with Black race (odds ratio, OR 6.59), substance use (2.81), and failure to graduate high school (OR 9.59) [27].…”

JPGN and the Year 2022

“…Multiple demographic, clinical, and psychosocial factors from childhood are independently associated with adult death after pediatric LT. In a retrospective cohort study of 101 children who underwent LT and were transferred to adult care between 2000 and 2015, 93 followed with an adult provider, while 8 were lost to follow up (13). In total 23 of 93 patients died after transfer (24.7%).…”

Insights on Transition of Care‐Related Deaths of Young Adults Who Were Recipients of Pediatric Liver Transplantation

“…The paper appearing in this issue of JPGN by Stevens et al (5) which investigated the role played by numerous demographic, clinical, and psychosocial characteristics in the long-term outcome of pediatric liver transplant recipients transitioning to adult providers' care is therefore particularly welcome. In fact, the authors with a quite well-designed study add a new tile to this complex mosaic, which helps (a) to shed more light on the causes behind death and loss to FU after transition, (b) to risk-stratify adolescents and formulate as much as possible individualized future approaches to their transition of care.…”

“…In summary and overall, it is evident that in this special population (1) long‐term issues, psychosocial aspects, quality of life and nonadherence are important issues with some still unmet goals, (2) no existing pediatric‐to‐adult care transition program after liver transplantation is perfect or adequately fulfilling all the planned requirements. Future formal transition programs could benefit from the results of the study of Stevens et al (5) in the early identification of high‐risk pediatric liver transplant recipients during the transfer to adult facilities, and in focusing on modifiable factors such as academic outcomes and substance abuse careful prevention. The same conclusions would probably be applicable to any adolescent with a chronic liver condition who will transition to an adult provider.…”