Socioeconomic disparities in long-term outcomes after pediatric liver transplantation in a universal healthcare system: a population-based study

We conducted a population-based cohort study of pediatric liver transplantation (LT) in Ontario, Canada, a universal healthcare setting, to quantify survivorship burden relative to matched general-population controls and assess whether socioeconomic status (SES) modified these differences. First, isolated pediatric LTs (1991–2021) were linked to provincial administrative data and matched 1:5 on sex and birth year to general-population controls. Outcomes were mortality, chronic conditions, de novo cancers, and live births, with prespecified SES interaction analyses. Among 449 LT recipients and 2,245 controls (median age 1.9 years), 20-year survival was 78%. At 10 years, LT recipients had higher cumulative incidence of mood disorders (16.1% vs 8.77%; IRR 3.61, 95% CI 2.9–4.5) and de novo cancer (7.83% vs 0.19%; IRR 25.1, 95% CI 12.1–52.0), with cancer excess concentrated in the first 5 years. In a female-only landmark analysis beginning at age 15, live-birth incidence was similar between groups (IRR 0.75, 95% CI 0.39–1.44), suggesting childhood LT does not necessarily preclude later family-building. Lower neighborhood income predicted higher post-LT mortality (adjusted HR 2.1, 95% CI 1.2–3.7). Despite universal healthcare, socioeconomic disadvantage was associated with worse long-term outcomes; integrating social determinants of health into survivorship care is needed.