Beyond biological risk: socioeconomic vulnerability and adverse pediatric kidney transplant outcomes

Background: Adverse social determinants are known contributors to poorer long-term allograft outcomes. Yet optimal measures of social determinants are lacking. We sought to evaluate the association between socioeconomic status (SES) and graft loss in children using several different metrics of social determinants of health (SDOH). Methods: Our study included 137 pediatric kidney transplant recipients (< 18 years at kidney failure onset) transplanted between 2010 and 2020. The association between SES measures (individual- and area-level) and graft survival was examined using Cox regression models. Measures were dichotomized: HOUSES Index [low SES(Q1) vs. high (Q2–Q4)], Area Deprivation Index (ADI) [high deprivation (76–100 percentile) vs. low (1–75 percentile)], and Childhood Opportunity Index (COI) [low opportunity (1s–25 percentile) vs. high (26–100)]. All models were adjusted for transplant age, sex, donor type, pretransplant dialysis, insurance, kidney failure cause, and body mass index z-score. Results: After adjusting for covariates, we observed a significantly increased risk of graft loss in HOUSES Q1 vs. Q2–4 recipients (adjusted hazard ratio [aHR]: 3.25; 95% CI: 1.38, 7.64; p = 0.007) and nationally standardized low-opportunity COI vs. high-opportunity COI recipients (aHR: 5.01; 95% CI: 2.01, 12.5; p = 0.001). In contrast, we observed no significant association between ADI and graft loss. Conclusions: Using the HOUSES Index and COI, we identified a 3-fold to fivefold higher risk of pediatric graft loss among recipients with lower SDOH. These tools provide robust non-biological predictors for transplant outcomes; however, larger studies are required to compare their relative impact.