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. 2025 Jun 1;109(6):976-984.
doi: 10.1097/TP.0000000000005328. Epub 2025 Jan 9.

Association of Community Socioeconomic Distress With Waitlist and Survival Outcomes in Liver Transplantation

Sara Sakowitz  1 , Syed Shahyan Bakhtiyar  1   2 , Saad Mallick  1 , Fady Kaldas  3 , Peyman Benharash  1   4
Affiliations

Association of Community Socioeconomic Distress With Waitlist and Survival Outcomes in Liver Transplantation

Sara Sakowitz et al. Transplantation. .

Abstract

Background: Despite efforts to ensure equitable access to liver transplantation (LT), significant disparities remain. Although prior literature has considered the effects of patient sex, race, and income, the contemporary impact of community socioeconomic disadvantage on outcomes after waitlisting for LT remains to be elucidated. We sought to evaluate the association of community-level socioeconomic deprivation with survival after waitlisting for LT.

Methods: All waitlisted candidates for isolated LT were identified using the 2005-2023 Organ Procurement and Transplantation Network. The previously validated Distressed Communities Index, representing poverty rate, median household income, unemployment, business growth, education level, and housing vacancies, was used to characterize community socioeconomic distress. Zip codes in the highest quintile were classified as the "distressed" cohort (others: "nondistressed"). Kaplan-Meier and Cox proportional hazard models were applied to assess patient and graft survival. We performed a Fine and Gray competing risk regression to consider the impact of distress on waitlist mortality.

Results: Of 169 601 patients, 95 020 (56%) underwent LT and 74 581 (44%) remained on the waitlist. Among transplanted patients, 18 774 (20%) were distressed. After adjustment, distressed faced similar posttransplant survival at 1 y but greater mortality hazard at 5 y (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.04-1.12) and 10 y (HR, 1.09; 95% CI, 1.05-1.12). Considering all waitlisted patients, competing risk analysis demonstrated distressed candidates to face significantly greater cumulative incidence of death/deterioration on the waitlist (HR, 1.07; 95% CI, 1.04-1.11).

Conclusions: Community-level socioeconomic inequity is associated with greater waitlist mortality and inferior post-LT survival. Novel interventions are needed to address structural barriers to care and continued inequities in outcomes.

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Conflict of interest statement

The authors declare no funding or conflicts of interest.

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