Background: Despite the existence of institutional protocols, liver transplant centers often have variability in early immunosuppression practices. We aimed to measure within-center variability in early immunosuppression after pediatric liver transplant (LT) and examine its association with one-year outcomes.
Methods: We analyzed pediatric LTs from 2013 to 2018 in the United Network for Organ Sharing registry, with data aggregated by center. We categorized induction regimen as corticosteroids only vs. T-cell depleting antibody vs. non-T-cell depleting antibody. Primary exposures were coefficient of immunosuppression variability (CIV) in (1) induction and (2) mycophenolate mofetil (MMF) use. Primary outcomes were one-year graft survival, patient survival, and acute rejection rate within the first year after transplant.
Results: The study cohort included 2542 LT recipients from 67 LT centers. Sixteen centers (24%) had no MMF variability; twenty-five centers (37%) had no induction variability. In multivariable analysis, induction CIV was associated with 2.72 times greater odds of acute rejection in the first year (OR 2.72; 95% CI 1.66-4.45; p < 0.001). MMF CIV was not associated with rejection (OR 1.22, 95% CI 0.66-2.25, p = 0.527). Neither one-year graft nor patient survival were associated with induction or MMF CIV.
Conclusions: Induction CIV is associated with higher one-year acute rejection odds and did not impact short-term graft or patient survival. Improved understanding of the reasons for high CIV will inform future work aiming to determine whether reducing variability may improve outcomes.
Keywords: anti‐thymocyte globulin; basiliximab; corticosteroids; mycophenolate mofetil; t‐cell depleting antibody.
© 2025 The Author(s). Pediatric Transplantation published by Wiley Periodicals LLC.