*Purpose: With improvements in surgical technique and immunosuppressive regimens, many pediatric liver transplant recipients are surviving to adulthood. Successful transition to an adult provider is key to a patient’s continued well-being. Mortality rates remain high in young adults with chronic medical conditions in the years following transfer. The purpose of our study is to analyze the relationship between demographic, psychosocial and clinical factors in children who received a liver transplant to assess risk of death or loss to follow-up in adulthood.

*Methods: Retrospective, single center cohort study of patients who underwent pediatric liver transplantation between 1990-2015 at a large tertiary transplant center. Patient data was collected via electronic medical records, a national transplant database, telephone interview, and public death records.

*Results: 120 patients were transferred to adult care, of which 101 met inclusion criteria. Sixty-four patients (63%) transferred to an affiliated adult facility, 29 (29%) were followed by another healthcare system, and 8 (8%) were lost to follow-up. In all, 23 patients died after transfer (25%). Several childhood factors were associated with higher rates of adult death: African American (AA) race (OR 6.59, p<0.001); psychiatric illness or substance use (OR 2.81, p=0.039); not obtaining a high school (HS) diploma (OR 9.59, p<0.001); medication non-adherence (OR 4.72, p=0.02); pediatric acute cellular rejection (OR 4.44, p=0.025); and co-morbidities of diabetes mellitus (DM) (OR 5.71, p=0.001) or renal insufficiency (OR 2.82, p=0.043). Not graduating HS was also associated with loss to follow-up (p<0.001). On multivariate analysis, AA race, substance use, and DM retained the highest association with adult death (OR 7.47, 9.16, and 3.76 respectively, all p<0.05). Not graduating HS was collinear with these factors, with an OR 9.65, p=0.011.

*Conclusions: Complex, intertwined demographic, psychosocial and clinical factors are associated with increased rates of death in pediatric liver transplant recipients after transfer to adult care. Early recognition of high-risk patients, individualized transition processes, and further investigation into underlying causes of health disparities may improve long-term outcomes.

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