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

We conducted a population-based cohort study of pediatric liver transplantation (LT) in Ontario, Canada, a universal health care setting, to quantify survivorship burden relative to matched general-population controls and assess whether socioeconomic status 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 socioeconomic status interaction analyses. Among 449 LT recipients and 2245 controls (median age, 1.9 years), 20-year survival was 78%. At 10 years, LT recipients had a higher cumulative incidence of mood disorders (16.1% vs 8.77%; incidence rate ratio [IRR], 3.61; 95% confidence interval [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 years, 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 hazard ratio, 2.1; 95% CI, 1.2-3.7). Despite universal health care, socioeconomic disadvantage was associated with worse long-term outcomes; integrating social determinants of health into survivorship care is needed.