1. Vittorio J. Kosmach-Park B. Wadhwani S. Jackson W. Kerkar N. Corbo H. Vekaria P. Gupta N. Yeh H. King LY. "Adult provider role in transition of care for young adult pediatric recipients of liver transplant: An expert position statement." Hepatology communications, 8, Aug 2024. .

    Abstract...

    Health care transition (HCT) is the process of changing from a pediatric to an adult model of care. Young adult pediatric recipients of liver transplant transferring from pediatric to adult health care services are highly vulnerable and subject to poor long-term outcomes. Barriers to successful transition are multifaceted. A comprehensive HCT program should be initiated early in pediatrics and continued throughout young adulthood, even after transfer of care has been completed. It is critical that pediatric and adult liver transplant providers establish a partnership to optimize care for these patients. Adult providers must recognize the importance of HCT and the need to continue the transition process following transfer. While this continued focus on HCT is essential, current literature has primarily offered guidance for pediatric providers. This position paper outlines a framework with a sample set of tools for the implementation of a standardized, multidisciplinary approach to HCT for adult transplant providers utilizing "The Six Core Elements of HCT." To implement more effective strategies and work to improve long-term outcomes for young adult patients undergoing liver transplant, HCT must be mandated as a routine part of posttransplant care. Increased advocacy efforts with the additional backing and support of governing organizations are required to help facilitate these practices.
  2. Gutierrez SA. Chiou SH. Rhee S. Lai JC. Wadhwani SI. "The influence of neighborhood income on healthcare utilization in pediatric liver transplant." Journal of pediatric gastroenterology and nutrition, 79, Jul 2024. 100-109.

    Abstract...

    Neighborhood contextual factors are associated with liver transplant outcomes. We analyzed associations between neighborhood-level socioeconomic status and healthcare utilization for pediatric liver transplant recipients.
  3. Wadhwani SI. Alvarado A. Shifman HP. Bautista B. Yalung J. Squires JE. Campbell K. Ebel NH. Hsu E. Vittorio J. Zielsdorf S. Desai DM. Bucuvalas JC. Gottlieb L. Kotagal U. Lyles CR. Ackerman SL. Lai JC. "Caregivers' and providers' perspectives of social and medical care after pediatric liver transplant: Results from the multicenter SOCIAL-Tx study." Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 30, Jul 2024. 717-727.

    Abstract...

    Disparities exist in pediatric liver transplant (LT). We characterized barriers and facilitators to providing transplant and social care within pediatric LT clinics. This was a multicenter qualitative study. We oversampled caregivers reporting household financial strain, material economic hardship, or demonstrating poor health literacy. We also enrolled transplant team members. We conducted semistructured interviews with participants. Caregiver interviews focused on challenges addressing transplant and household needs. Transplant provider interviews focused on barriers and facilitators to providing social care within transplant teams. Interviews were recorded, transcribed, and coded according to the Capability, Opportunity, Motivation-Behavior model. We interviewed 27 caregivers and 27 transplant team members. Fifty-two percent of caregivers reported a household income <$60,000, and 62% reported financial resource strain. Caregivers reported experiencing (1) high financial burdens after LT, (2) added caregiving labor that compounds the financial burden, (3) dependency on their social network's generosity for financial and logistical support, and (4) additional support being limited to the perioperative period. Transplant providers reported (1) relying on the pretransplant psychosocial assessment for identifying social risks, (2) discomfort initiating social risk discussions in the post-transplant period, (3) reliance on social workers to address new social risks, and (4) social workers feeling overburdened by quantity and quality of the social work referrals. We identified barriers to providing effective social care in pediatric LT, primarily a lack of comfort in assessing and addressing new social risks in the post-transplant period. Addressing these barriers should enhance social care delivery and improve outcomes for these children.
  4. Gutierrez SA. Chiou SH. Raghu V. Cole CR. Rhee S. Lai JC. Wadhwani SI. "Associations between hospital-level socioeconomic patient mix and rates of central line-associated bloodstream infections in short bowel syndrome: A retrospective cohort study." JPEN. Journal of parenteral and enteral nutrition, , Jun 2024. .

    Abstract...

    Low neighborhood income is linked with increased hospitalizations for central line-associated bloodstream infections (CLABSIs) in pediatric short bowel syndrome (SBS). We assessed whether this relationship varies by hospital center.
  5. Shifman HP. Hatchett J. Pai RA. Safer R. Gomel R. Vyas M. Li M. Lai JC. Wadhwani SI. "Caregiver-reported symptom burden and preferences for therapeutic goals in pediatric primary sclerosing cholangitis." Journal of pediatric gastroenterology and nutrition, , Jun 2024. .

    Abstract...

    This study analyzed qualitative and quantitative survey responses from 51 pediatric primary sclerosing cholangitis (PSC) patients and caregivers using the PSC Partners Patient Registry-Our Voices survey. The most common symptoms reported by children/caregivers include: fatigue (71%), abdominal pain (69%), anxiety (59%), appetite loss (51%), insomnia (49%), and pruritus (45%). When experiencing symptoms at their worst, over half of patients/caregivers reported limitations in physically demanding activities (67%), work/school duties (63%), social life activities (55%), and activities for fun or exercise (53%). Over half of patients/caregivers expressed willingness to participate in clinical trials, however none reported ever participating in trials for new or investigational PSC drugs. This study revealed a substantial patient/caregiver-reported symptom burden for children with PSC that impacts quality of life and limits access to clinical trials. Future efforts should focus on developing patient-centered clinical endpoints for PSC trials, increasing trial availability for pediatric PSC patients, and reducing logistical barriers to trial involvement.
  6. Bonn J. Ambrosino T. Rich K. Taylor A. Wadhwani SI. "Implementation of a multicomponent medication adherence promotion system is associated with a decrease in late T-cell-mediated rejection." Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, , May 2024. .

    Abstract...

    Poor immunosuppression adherence in pediatric recipients of liver transplant (LT) contributes to late T-cell-mediated rejection (TCMR) in ~90% of cases and increases the risk of mortality. A medication adherence promotion system (MAPS) was found to reduce late rejection in pediatric recipients of kidney transplants. Using quality improvement methodology, we adapted and implemented the MAPS in our LT clinic. Our primary outcome was population-level rates of late TCMR, measured as a monthly incident rate. Three-hundred fourteen patients undergoing LT are currently cared for at our institution. One-hundred sixty-two (52%) are females with a median age of 16 years and a median age at LT of 2 years. Preimplementation, monthly rejection rates were 0.84 rejections per 100 patient-months. After iterative implementation of MAPS over 2.3 years, monthly rejection rates decreased to 0.46 rejections per 100 patient-months, a 45% decrease in late TCMR. Implementation of MAPS was associated with a sustained 45% decrease in TCMR at a single center, suggesting that quality improvement tools may help improve clinical outcomes. MAPS may be an important tool to ensure long-term allograft health. Future studies should rigorously test MAPS across a multicenter sample.
  7. Wadhwani SI. Kruse G. Squires J. Ebel N. Gupta N. Campbell K. Hsu E. Zielsdorf S. Vittorio J. Desai DM. Bucuvalas JC. Gottlieb LM. Lai JC. "Caregiver Perceptions of Social Risk Screening in Pediatric Liver Transplantation: From the Multicenter SOCIAL-Tx Study." Transplantation, 108, Apr 2024. 940-946.

    Abstract...

    The social determinants of health contribute to adverse post-liver transplant outcomes. Identifying unmet social risks may enable transplant teams to improve long-term outcomes for at-risk children. However, providers may feel uncomfortable asking about household-level social risks in the posttransplant period because they might make their patients/families uncomfortable.
  8. Yalung JE. Shifman HP. Manning ER. Beck A. Bucuvalas J. Lai JC. Wadhwani SI. "Ambient air pollution is associated with graft failure/death in pediatric liver transplant recipients." American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons, 24, Mar 2024. 448-457.

    Abstract...

    Children exposed to disproportionately higher levels of air pollution experience worse health outcomes. In this population-based, observational registry study, we examine the association between air pollution and graft failure/death in children following liver transplantation (LT) in the US. We modeled the associations between air pollution (PM) levels localized to the patient's ZIP code at the time of transplant and graft failure or death using Cox proportional-hazards models in pediatric LT recipients aged <19 years in the US from 2005-2015. In univariable analysis, high neighborhood PM was associated with a 56% increased hazard of graft failure/death (HR: 1.56; 95% CI: 1.32, 1.83; P < .001). In multivariable analysis, high neighborhood PM was associated with a 54% increased risk of graft failure/death (HR: 1.54; 95% CI: 1.29, 1.83; P < .001) after adjusting for race as a proxy for racism, insurance status, rurality, and neighborhood socioeconomic deprivation. Children living in high air pollution neighborhoods have an increased risk of graft failure and death posttransplant, even after controlling for sociodemographic variables. Our findings add further evidence that air pollution contributes to adverse health outcomes for children posttransplant and lay the groundwork for future studies to evaluate underlying mechanisms linking PM to adverse LT outcomes.
  9. Wadhwani SI. Pantell MS. Winestone LE. "Subspecialty Pediatrics: An Unmet Opportunity to Address Unmet Social Risks." Academic pediatrics, 24, Mar 2024. 204-207.

    Abstract...

  10. Gutierrez SA. Pathak S. Raghu V. Shui A. Huang CY. Rhee S. McKenzie-Sampson S. Lai JC. Wadhwani SI. "Neighborhood Income Is Associated with Health Care Use in Pediatric Short Bowel Syndrome." The Journal of pediatrics, 265, Feb 2024. 113819.

    Abstract...

    To evaluate associations between neighborhood income and burden of hospitalizations for children with short bowel syndrome (SBS).
  11. Shifman HP. Huang CY. Beck AF. Bucuvalas J. Perito ER. Hsu EK. Ebel NH. Lai JC. Wadhwani SI. "Association of state Medicaid expansion policies with pediatric liver transplant outcomes." American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons, 24, Feb 2024. 239-249.

    Abstract...

    Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.
  12. Cullaro G. Ge J. Lee BP. Lai JC. Wadhwani SI. "Association between neighborhood-based material deprivation and liver transplant waitlist registrants demographics and mortality." Clinical transplantation, 38, Jan 2024. e15189.

    Abstract...

    Liver transplantation for alcohol-related liver disease (ARLD) has increased. We examined temporal trends in ARLD listing practices by neighborhood deprivation and evaluated the impact of neighborhood deprivation on waitlist mortality.
  13. Ha NB. Fan B. Seetharaman S. Kent DS. Yao F. Shui AM. Huang CY. Wadhwani SI. Lai JC. "Variation in skeletal muscle mass among patients with cirrhosis of different self-identified race/ethnicity." JGH open : an open access journal of gastroenterology and hepatology, 7, Oct 2023. 724-727.

    Abstract...

    Skeletal muscle index (SMI) remains a strong predictor of mortality in cirrhosis patients. However, the extent to which SMI varies by race/ethnicity has not been fully evaluated. Among 317 patients, 55% identified themselves as non-Hispanic White (NHW), 26% Hispanic White (HW), 13% Asian, and 6% Black. There was significant variation in SMI by race/ethnicity; median SMI was lowest in Asian and highest in Black patients. There were significant differences of sarcopenia by race/ethnicity using established SMI cutpoints: 48% NHW, 33% HW, 67% Asian, and 37% Black ( = 0.003). Using these cutpoints, SMI was significantly associated with waitlist mortality only in NHW patients but not in other racial/ethnic groups.
  14. Chen VL. Song MW. Suresh D. Wadhwani SI. Perumalswami P. "Effects of social determinants of health on mortality and incident liver-related events and cardiovascular disease in steatotic liver disease." Alimentary pharmacology & therapeutics, 58, Sep 2023. 537-545.

    Abstract...

    Social determinants of health (SDOH) are becoming increasingly recognised as mediators of human health. In the setting of metabolic dysfunction-associated steatotic liver disease (MASLD), most of the literature on SDOH relates to individual-level risk factors. However, there are very limited data on neighbourhood-level SDOH in MASLD.
  15. Yilma M. Dalal N. Wadhwani SI. Hirose R. Mehta N. "Geographic disparities in access to liver transplantation." Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 29, Sep 2023. 987-997.

    Abstract...

    Since the Final Rule regarding transplantation was published in 1999, organ distribution policies have been implemented to reduce geographic disparity. While a recent change in liver allocation, termed acuity circles, eliminated the donor service area as a unit of distribution to decrease the geographic disparity of waitlisted patients to liver transplantation, recently published results highlight the complexity of addressing geographic disparity. From geographic variation in donor supply, as well as liver disease burden and differing model for end-stage liver disease (MELD) scores of candidates and MELD scores necessary to receive liver transplantation, to the urban-rural disparity in specialty care access, and to neighborhood deprivation (community measure of socioeconomic status) in liver transplant access, addressing disparities of access will require a multipronged approach at the patient, transplant center, and national level. Herein, we review the current knowledge of these disparities-from variation in larger (regional) to smaller (census tract or zip code) levels to the common etiologies of liver disease, which are particularly affected by these geographic boundaries. The geographic disparity in liver transplant access must balance the limited organ supply with the growing demand. We must identify patient-level factors that contribute to their geographic disparity and incorporate these findings at the transplant center level to develop targeted interventions. We must simultaneously work at the national level to standardize and share patient data (including socioeconomic status and geographic social deprivation indices) to better understand the factors that contribute to the geographic disparity. The complex interplay between organ distribution policy, referral patterns, and variable waitlisting practices with the proportion of high MELD patients and differences in potential donor supply must all be considered to create a national policy strategy to address the inequities in the system.
  16. Wang M. Wadhwani SI. Cullaro G. Lai JC. Rubin JB. "Racial and Ethnic Disparities Among Patients Hospitalized for Acute Cholangitis in the United States." Journal of clinical gastroenterology, 57, Aug 2023. 731-736.

    Abstract...

    We sought to determine whether race/ethnicity is associated with hospitalization outcomes among patients admitted with acute cholangitis.
  17. Wadhwani SI. Kumar WM. Hsu EK. "Towards equity in paediatric liver transplantation: improving access and long-term outcomes." The lancet. Gastroenterology & hepatology, 8, Jul 2023. 600-602.

    Abstract...

  18. Ge J. Lai JC. Wadhwani SI. "Novel approaches are needed to study social determinants of health in liver transplantation." Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 29, Mar 2023. 241-243.

    Abstract...

  19. Wadhwani SI. Lai JC. "The digital determinants of liver disease." Hepatology (Baltimore, Md.), 77, Jan 2023. 13-14.

    Abstract...

  20. Wadhwani SI. Barrera AG. Shifman HP. Baker E. Bucuvalas J. Gottlieb LM. Kotagal U. Rhee SJ. Lai JC. Lyles CR. "Caregiver perspectives on the everyday medical and social needs of long-term pediatric liver transplant patients." Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 28, Nov 2022. 1735-1746.

    Abstract...

    Using in-depth interviews, we sought to characterize the everyday medical and social needs of pediatric liver transplant caregivers to inform the future design of solutions to improve care processes. Participants (parents/caregivers of pediatric liver transplant recipients) completed a survey (assessing socioeconomic status, economic hardship, health literacy, and social isolation). We then asked participants to undergo a 60-min virtual, semistructured qualitative interview to understand the everyday medical and social needs of the caregiver and their household. We intentionally oversampled caregivers who reported a social or economic hardship on the survey. Transcripts were analyzed using thematic analysis and organized around the Capability, Opportunity, Motivation-Behavior model. A total of 18 caregivers participated. Of the participants, 50% reported some form of financial strain, and about half had less than 4 years of college education. Caregivers had high motivation and capability in executing transplant-related tasks but identified several opportunities for improving care. Caregivers perceived the health system to lack capability in identifying and intervening on specific family social needs. Caregiver interviews revealed multiple areas in which family supports could be strengthened, including (1) managing indirect costs of prolonged hospitalizations (e.g., food, parking), (2) communicating with employers to support families' needs, (3) coordinating care across hospital departments, and (4) clarifying care team roles in helping families reduce both medical and social barriers. This study highlights the caregiver perspective on barriers and facilitators to posttransplant care. Future work should identify whether these themes are present across transplant centers. Caregiver perspectives should help inform future interventions aimed at improving long-term outcomes for children after liver transplantation.
  21. Berry KA. Kent D. Seetharaman S. Wong R. Mohamad Y. Yao F. Nunez-Duarte M. Wadhwani SI. Boyarsky BJ. Rahimi RS. Duarte-Rojo A. Kappus MR. Volk ML. Ladner DP. Segev DL. McAdams-DeMarco M. Verna EC. Ganger DR. Lai JC. "Loneliness in adults awaiting liver transplantation at 7 U.S. transplant centers." Annals of hepatology, 27, 2022. 100718.

    Abstract...

    Loneliness, "a subjective feeling of being isolated", is a strong predictor of adverse health. We characterized loneliness in patients with end-stage liver disease (ESLD) awaiting liver transplantation (LT).
  22. Ebel NH. Lai JC. Bucuvalas JC. Wadhwani SI. "A review of racial, socioeconomic, and geographic disparities in pediatric liver transplantation." Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 28, Sep 2022. 1520-1528.

    Abstract...

    Equity is a core principle in both pediatrics and solid organ transplantation. Health inequities, specifically across race, socioeconomic position, or geography, reflect a moral failure. Ethical principles of prudential life span, maximin principle, and fair innings argue for allocation priority to children related to the number of life years gained, equal access to transplant, and equal opportunity for ideal posttransplant outcomes. Iterative policy changes have aimed to narrow these disparities to achieve pediatric transplant equity. These policy changes have focused on modifying pediatric priority for organ allocation to eliminate mortality on the pediatric transplant waiting list. Yet disparities remain in pediatric liver transplantation at all time points: from access to referral for transplantation, likelihood of living donor transplantation, use of exception narratives, waitlist mortality, and inequitable posttransplant outcomes. Black children are less likely to be petitioned for exception scores, have higher waitlist mortality, are less likely to be the recipient of a living donor transplant, and have worse posttransplant outcomes compared with White children. Children living in the most socioeconomically deprived neighborhoods have worse posttransplant outcomes. Children living farther from a transplant center have higher waitlist mortality. Herein we review the current knowledge of these racial and ethnic, socioeconomic, and geographic disparities for these children. To achieve equity, stakeholder engagement is required at all levels from providers and health delivery systems, learning networks, institutions, and society. Future initiatives must be swift, bold, and effective with the tripartite mission to inform policy changes, improve health care delivery, and optimize resource allocation to provide equitable transplant access, waitlist survival, and posttransplant outcomes for all children.
  23. Wadhwani SI. Lai JC. Gottlieb L. "Medical Need and Transplant Accessibility-Reply." JAMA, 328, Aug 2022. 679-680.

    Abstract...

  24. Shifman HP. Rasnick E. Huang CY. Beck AF. Bucuvalas J. Lai JC. Wadhwani SI. "Association of Primary Care Shortage Areas with Adverse Outcomes after Pediatric Liver Transplant." The Journal of pediatrics, 246, Jul 2022. 103-109.e2.

    Abstract...

    To characterize associations between living in primary care shortage areas and graft failure/death for children after liver transplantation.
  25. Wadhwani SI. Lai JC. Gottlieb LM. "Medical Need, Financial Resources, and Transplant Accessibility." JAMA, 327, Apr 2022. 1445-1446.

    Abstract...

  26. Wadhwani SI. Ge J. Gottlieb L. Lyles C. Beck AF. Bucuvalas J. Neuhaus J. Kotagal U. Lai JC. "Racial/ethnic disparities in wait-list outcomes are only partly explained by socioeconomic deprivation among children awaiting liver transplantation." Hepatology (Baltimore, Md.), 75, Jan 2022. 115-124.

    Abstract...

    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.
  27. Wadhwani SI. Gottlieb L. Bucuvalas JC. Lyles C. Lai JC. "Addressing Social Adversity to Improve Outcomes for Children After Liver Transplant." Hepatology (Baltimore, Md.), 74, Nov 2021. 2824-2830.

    Abstract...

    The social determinants of health, defined as the conditions in which we live, learn, work, and play, undoubtedly impact health outcomes. Social adversity in childhood perpetuates over the life course and has consequences extending into adulthood. This link between social adversity and adverse outcomes extends to children undergoing liver transplant, with children from socioeconomically deprived neighborhoods experiencing a greater burden of morbidity and mortality after transplant. Yet, we lack an in-depth understanding of how to address social adversity for these children. Herein, we lay out a strategy to develop and test interventions to address social adversity for children undergoing liver transplant. To do so, we believe that more granular data on how specific social risk factors (e.g., food insecurity) impact outcomes for children after liver transplant are needed. This will provide the liver transplant community with knowledge on the most pressing problems. Then, using the National Academies of Sciences, Engineering, and Medicine's framework for integrating social needs into medical care, the health system can start to develop and test health system interventions. We believe that attending to our patients' social adversity will realize improved outcomes for children undergoing liver transplant.
  28. Wadhwani SI. Huang CY. Gottlieb L. Beck AF. Bucuvalas J. Kotagal U. Lyles C. Lai JC. "Center variation in long-term outcomes for socioeconomically deprived children." American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons, 21, Sep 2021. 3123-3132.

    Abstract...

    Neighborhood socioeconomic deprivation is associated with adverse outcomes after pediatric liver transplant. We sought to determine if this relationship varies by transplant center. Using SRTR, we included patients <18 years transplanted 2008-2013 (N = 2804). We matched patient ZIP codes to a deprivation index (range [0,1]; higher values indicate increased socioeconomic deprivation). A center-level patient-mix deprivation index was defined by the distribution of patient-level deprivation. Centers (n = 66) were classified as high or low deprivation if their patient-mix deprivation index was above or below the median across centers. Center quality was classified as low or high graft failure if graft survival rates were better or worse than the overall 10-year graft survival rate. Primary outcome was patient-level graft survival. We used random-effect Cox models to evaluate center-level covariates on graft failure. We modeled center quality using stratified Cox models. In multivariate analysis, each 0.1 increase in the patient-mix deprivation index was associated with increased hazard of graft failure (HR 1.32; 95%CI: 1.05, 1.66). When stratified by center quality, patient-mix deprivation was no longer significant (HR 1.07, 95%CI: 0.89, 1.28). Some transplant centers care for predominantly high deprivation children and maintain excellent outcomes. Revealing and replicating these centers' practice patterns should enable more equitable outcomes.
  29. Wadhwani SI. Brokamp C. Rasnick E. Bucuvalas JC. Lai JC. Beck AF. "Neighborhood socioeconomic deprivation, racial segregation, and organ donation across 5 states." American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons, 21, Mar 2021. 1206-1214.

    Abstract...

    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.
  30. Wadhwani SI. Bucuvalas JC. Brokamp C. Anand R. Gupta A. Taylor S. Shemesh E. Beck AF. "Association Between Neighborhood-level Socioeconomic Deprivation and the Medication Level Variability Index for Children Following Liver Transplantation." Transplantation, 104, Nov 2020. 2346-2353.

    Abstract...

    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.
  31. Wadhwani SI. Beck AF. Bucuvalas J. Gottlieb L. Kotagal U. Lai JC. "Neighborhood socioeconomic deprivation is associated with worse patient and graft survival following pediatric liver transplantation." American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons, 20, Jun 2020. 1597-1605.

    Abstract...

    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.
  32. Wadhwani SI. Nichols M. Klosterkemper J. Cirincione R. Whitesell K. Owen D. Rengering R. Walz B. Heubi J. Hooper DK. "Implementing a Process to Systematically Identify and Address Poor Medication Adherence in Pediatric Liver Transplant Recipients." Pediatric quality & safety, 5, 2020. e296.

    Abstract...

    Poor adherence to medication following pediatric liver transplantation remains a major challenge, with some estimates suggesting that 50% of adolescent liver transplant recipients exhibit reduced medication adherence. To date, no gold standard has emerged to address this challenge; however, system interventions are most likely to be successful. We sought to implement a system to identify and address adherence barriers in a liver transplant clinic.
  33. Lyles JL. Wadhwani SI. Bolton SM. Mouzaki M. "Methamphetamine-induced Acute Esophagitis in a 16-Year-old Girl." Journal of pediatric gastroenterology and nutrition, 70, Apr 2020. e86-e87.

    Abstract...

  34. Wadhwani SI. "50 Years Ago in TheJournalofPediatrics: The Diagnostic Value of Gamma Glutamyl Transpeptidase in Children and Adolescents with Liver Disease." The Journal of pediatrics, 214, Nov 2019. 164.

    Abstract...

  35. Wadhwani SI. Hsu EK. Shaffer ML. Anand R. Ng VL. Bucuvalas JC. "Predicting ideal outcome after pediatric liver transplantation: An exploratory study using machine learning analyses to leverage Studies of Pediatric Liver Transplantation Data." Pediatric transplantation, 23, Nov 2019. e13554.

    Abstract...

    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.
  36. Wadhwani SI. Nakayuenyongsuk W. Shinn L. Chase P. Kharbanda S. Bass D. Park KT. "Predictive Value of Fecal Calprotectin in Pediatric Graft-Versus-Host Disease." Journal of pediatric gastroenterology and nutrition, 63, Dec 2016. e208-e209.

    Abstract...

  37. Wadhwani SI. Turmelle YP. Nagy R. Lowell J. Dillon P. Shepherd RW. "Prolonged neonatal jaundice and the diagnosis of biliary atresia: a single-center analysis of trends in age at diagnosis and outcomes." Pediatrics, 121, May 2008. e1438-40.

    Abstract...

    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.