Racial Disparities in Pediatric Patients With Cholestatic Liver Disease Undergoing Liver Transplant: A UNOS Database Study

Introduction Cholestatic liver disease is the leading indication for pediatric liver transplantation (LT). Early detection and optimal care are often limited by socioeconomic barriers including racial disparities. This study examined racial disparities in demographics, waitlists, and post‐transplant outcomes among pediatric LT recipients with cholestatic liver disease. Methods All pediatric patients (≤ 18 years) who were listed or received LT for cholestatic liver disease (Biliary Atresia, Caroli's, Choledochal cyst, PSC, PFIC, Alagille, and other non‐specified cholestatic diseases) between 2010 and 2024 were retrospectively identified using the United Network for Organ Sharing (UNOS) database. The primary outcome of the study was waitlist mortality, graft failure, and post‐transplant mortality stratified by race, specifically non‐Hispanic whites (NHW), non‐Hispanic blacks (NHBs), Hispanics, and others. Results 3501 pediatric patients underwent LT for cholestatic liver disease: 1663 (47.5%) were NHW, 795 (22.7%) were Hispanic, 648 (18.5%) were NHB, and 395 (11.3%) were of other races. NHW recipients were more likely to have private insurance (56.7% vs. 18.2%, p < 0.01) and experienced shorter waitlist times than Hispanic patients (175.9 vs. 189.4 days, p < 0.01). The 1‐year survival rate was lower in NHB than in NHW recipients (94.8% vs. 96.8%, p = 0.04), with no significant difference at 5 years (93.7% vs. 95.4%, p = 0.13). Hispanic patients had similar 1‐year (95.9%, p = 0.26) and 5‐year (93.3%, p = 0.06) survival rates to NHW. NHB recipients had a significantly increased risk of mortality with a hazard ratio (HR) of 1.53 [95% CI: 1.05–2.22]. Predictive modeling using extreme gradient boosting showed a relative likelihood of increased mortality in NHB (3.91%) and Hispanic (3.14%) recipients. Conclusion Racial disparities significantly affect post‐transplant outcomes in pediatric cholestatic liver disease. NHB and Hispanic children face a risk of higher mortality despite similar waitlist outcomes, highlighting the need for targeted interventions to promote equity in pediatric liver transplantation.