Long‐term outcomes remain suboptimal following pediatric liver transplantation; only one third of children have normal biochemical liver function without immunosuppressant comorbidities 10 years posttransplant. We examined the association between an index of neighborhood socioeconomic deprivation with graft and patient survival using the Scientific Registry of Transplant Recipients. We included children <19 years who underwent liver transplantation between January 1, 2008 to December 31, 2013 (n = 2868). Primary exposure was a neighborhood socioeconomic deprivation index—linked via patient home ZIP code—with a range of 0‐1 (values nearing 1 indicate neighborhoods with greater socioeconomic deprivation). Primary outcome measures were graft failure and death, censored at 10 years posttransplant. We modeled survival using Cox proportional hazards. In univariable analysis, each 0.1 increase in the deprivation index was associated with a 14.3% (95% confidence interval [CI]): 3.8%‐25.8%) increased hazard of graft failure and a 12.5% (95% CI: 2.5%‐23.6%) increased hazard of death. In multivariable analysis adjusted for race, each 0.1 increase in the deprivation index was associated with a 11.5% (95% CI: 1.6%‐23.9%) increased hazard of graft failure and a 9.6% (95% CI: −0.04% to 20.7%) increased hazard of death. Children from high deprivation neighborhoods have diminished graft and patient survival following liver transplantation. Greater attention to neighborhood context may result in improved outcomes for children following liver transplantation.

Background: Neighborhood socioeconomic deprivation is associated with adverse health outcomes. We sought to determine if neighborhood socioeconomic deprivation was associated with adherence to immunosuppressive medications after liver transplantation. Methods:We conducted a secondary analysis of a multicenter, prospective cohort of children enrolled in the Medication Adherence in children who had a Liver Transplant study (enrollment 2010-2013). Participants (N=271) received a liver transplant ≥1 year prior to enrollment and were subsequently treated with tacrolimus. The primary exposure, connected to geocoded participant home addresses, was a neighborhood socioeconomic deprivation index (range 0-1, higher indicates more deprivation). The primary outcome was the Medication Level Variability Index (MLVI), a surrogate measure of adherence to immunosuppression in pediatric liver transplant recipients. Higher MVLI indicates worse adherence behavior; values ≥2.5 are predictive of late allograft rejection.Findings: There was a 5% increase in MLVI for each 0.1 increase in deprivation index (95%CI: −1%, 11%, p=0.08). Roughly 24% of participants from the most deprived quartile had an MLVI

Age at diagnosis is a modifiable risk factor in outcomes after hepatoportoenterostomy in biliary atresia; however, distinguishing biliary atresia from other more common causes of prolonged neonatal jaundice can be difficult. To focus attention on diagnosis of biliary atresia, we analyzed secular trends in the age at diagnosis, and other factors that might influence outcome. We performed a retrospective analysis of 55 consecutive infants with biliary atresia presenting to a single academic pediatric center over 15-year period from 1990 to 2004. The median age at diagnosis was 60 days (range: 21-152). In recent era (2000-2004), the median age was 69.0 days, compared with 48.5 days (1990-1994) and 59.5 days (1995-1999), respectively. Consistent with previous studies, the median age at diagnosis of those with poor outcomes (death or liver transplant) exceeded those with good outcomes after the hepatoportoenterostomy (72 vs 52 days, P < .001). The lack of improvement, or a concerning trends toward an increase in the age at diagnosis of biliary atresia, is perhaps attributable to neonatal follow-up practices. Efforts to make an earlier diagnose of this important condition deserve wider application and study.

Background and Aims: Racial/ethnic minority children have worse liver transplant (LT) outcomes. We evaluated whether neighborhood socioeconomic deprivation affected associations between race/ethnicity and wait-list mortality. Approach and Results:We included children (age <18) listed [2005][2006][2007][2008][2009][2010][2011][2012][2013][2014][2015] in the Scientific Registry of Transplant Recipients. We categorized patients as non-Hispanic White, Black, Hispanic, and other. We matched patient ZIP codes to a neighborhood socioeconomic deprivation index (range, 0-1; higher values indicate worse deprivation). Primary outcomes were wait-list mortality, defined as death/delisting for too sick, and receipt of living donor liver transplant (LDLT). Competing risk analyses modeled the association between race/ethnicity and wait-list mortality, with deceased donor liver transplant (DDLT) and LDLT as competing risks, and race/ethnicity and LDLT, with wait-list mortality and DDLT as competing risks. Of 7716 children, 17% and 24% identified as Black and Hispanic, respectively. Compared to White children, Black and Hispanic children had increased unadjusted hazard of wait-

Machine learning analyses allow for the consideration of numerous variables in order to accommodate complex relationships that would not otherwise be apparent in traditional statistical methods to better classify patient risk. The SPLIT registry data were analyzed to determine whether baseline demographic factors and clinical/biochemical factors in the first‐year post–transplant could predict ideal outcome at 3 years (IO‐3) after LT. Participants who received their first, isolated LT between 2002 and 2006 and had follow‐up data 3 years post–LT were included. IO‐3 was defined as alive at 3 years, normal ALT (<50) or GGT (<50), normal GFR, no non‐liver transplants, no cytopenias, and no PTLD. Heat map analysis and RFA were used to characterize the impact of baseline and 1‐year factors on IO‐3. 887/1482 SPLIT participants met inclusion criteria; 334 had IO‐3. Demographic, biochemical, and clinical variables did not elucidate a visual signal on heat map analysis. RFA identified non‐white race (vs white race), increased length of operation, vascular and biliary complications within 30 days, and duct‐to‐duct biliary anastomosis to be negatively associated with IO‐3. UNOS regions 2 and 5 were also identified as important factors. RFA had an accuracy rate of 0.71 (95% CI: 0.68‐0.74), PPV = 0.83, and NPV = 0.70. RFA identified participant variables that predicted IO‐3. These findings may allow for better risk stratification and personalization of care following pediatric liver transplantation.

A substantial and compelling body of evidence demonstrates that social determinants of health-where we live, eat, sleep, and play-impact health. 1 Social determinants are particularly relevant after transplant because self-management capacity influences medication adherence 2 and graft health. 3 We previously demonstrated that neighborhood-level socioeconomic deprivation, a composite measure derived from US Census Bureau data, is associated with patient-level posttransplant morbidity and mortality. 2,3 An outstanding question remains whether transplant care teams can mitigate the effects of neighborhood socioeconomic deprivation on long-term outcomes for children. To our knowledge, no studies to date have examined differences in transplant centers' long-term outcomes accounting for the contextual socioeconomic characteristics of the population served.There is significant center-to-center variation in pediatric liver transplantation protocols and outcomes, including organ offer

One in 10 people die awaiting transplantation from donor shortage. Only half of Americans register as organ donors. In this cross‐sectional study, we evaluated population‐level associations of neighborhood socioeconomic deprivation and racial segregation on organ donor registration rates. We analyzed state identification card demographic and organ donor registration data from 5 states to estimate the association between a neighborhood socioeconomic deprivation index (range [0, 1]; higher values indicate more deprivation) and a racial index of concentration at the extreme (ICE) (range [−1, 1]; lower values indicate predominantly black neighborhoods, higher values indicate predominantly white neighborhoods) on organ donor registration rates within a specified geography (census tract or ZIP code tabulation area [ZCTA]). Among 26 720 738 registrants, 32% of the sample were registered organ donors. At the census tract level, with each 0.1 decrease in the deprivation index, the organ donor registration rate increased by 6.8% (95% confidence interval [CI]: 6.6%, 7.0%). With each 0.1 increase in the racial ICE, the rate increased by 1.5% (95% CI: 1.5%, 1.6%). These associations held true at the ZCTA level. Areas with less socioeconomic deprivation and a higher concentration of white residents have higher organ donor registration rates. Public health initiatives should consider neighborhood context and novel data sources in designing optimal intervention strategies.

East Lancashire Hospitals NHS Trust, UKABSTRACT INTRODUCTION The aim of this study was to evaluate the influence of flurodeoxyglucose positron emission tomography computed tomography (FDG PET-CT), as an adjunct to conventional CT staging, in the detection of extrahepatic disease in patients with potentially resectable colorectal liver metastasis. METHODS Overall, 133 consecutive patients with colorectal liver metastases staged with CT and PET-CT referred to the East Lancashire regional hepatobiliary multidisciplinary team over a two-year period were included in this study. Abnormal findings on PET-CT were correlated with follow-up imaging and/or histology. All imaging was reviewed by specialist hepatobiliary radiologists for the presence/absence of extrahepatic disease. The influence of the PET-CT findings was categorised for each patient in relation to operability and other significant findings. RESULTS PET-CT had a major impact on staging of extra hepatic disease in 20% of patients, in comparison with the initial CT. Six per cent of patients were upstaged from operable CT findings to inoperable findings on PET-CT because of the discovery of inoperable occult extrahepatic disease. Five per cent had operable local regional nodal disease detected on PET-CT. A further 3% had premalignant colorectal lesions detected on PET-CT. Six per cent of patients were downstaged from indeterminate or suspected inoperable CT findings to operable findings on PET-CT. CONCLUSIONS The use of PET-CT in this setting may prevent futile operations, guide the resection of local regional nodal disease and downstage a number of patients thought to have extrahepatic disease on conventional imaging. This study has shown similar results to other recent studies and supports the use of PET-CT as a necessary staging modality in patients with potentially resectable colorectal liver metastases.