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Calculate Median MELD at Transplant around the Donor Hospital and Update Sorting within Liver Allocation

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eye iconAt a glance

Current policy

When candidates waiting for a liver transplant do not have a model for end-stage liver disease (MELD) or pediatric end-stage liver disease (PELD) score that appropriately reflects their medical urgency for transplant, the transplant program may request an exception score.

Currently, many exception scores are assigned based on the median MELD score at transplant (MMaT) around the transplant program where the candidate is listed. This results in higher exception scores for candidates listed at transplant programs with a higher MMaT.

Candidates are currently sorted within classifications on the match run using multiple factors, including waiting time at current MELD or PELD score and time spent on the waitlist at a higher MELD or PELD score.

Supporting media

Presentation

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Proposed changes

  • MELD exception scores will be based on the MMaT around the donor hospital rather than the transplant program where the candidate is registered.
  • The area around the donor hospital used for calculating MMaT will:
    • Need to meet a minimum threshold of at least two transplant programs and 10 transplants in the previous 365-day period.
    • Start with a 150 NM circle around the donor hospital and increase in 50 NM increments until minimum thresholds are met.
    • For donor hospitals in Hawaii and Puerto Rico, be modified so that the two transplant program threshold will not be required, but the 10 transplant threshold will. If there have not been 10 transplants within the prior 365-day period, the timeframe of evaluation will be extended to 730 days.
  • Waiting time used for sorting exception candidates on the match run will change to be length of time since the candidate’s earliest approved exception.
  • Non-exception candidates will be ranked ahead of the exception candidates when they have the same MELD or PELD score and blood type compatibility with the donor.

Anticipated impact

  • What it's expected to do
    • A candidate’s exception score will be based on a MMaT around the donor hospital
    • MELD exception scores will change with each match run due to varying MMaT’s for each donor hospital
    • Rank non-exception candidates ahead of exception candidates when they have the same MELD or PELD score and blood type compatibility with the donor
  • What it won't do
    • Will not change how median PELD score at transplant (MPaT) is calculated

Themes

  • Circle size used to calculate MMaT around donor hospital
  • Minimum number of transplant programs and number of transplants used to calculate MMaT
  • Calculation of MMaT at Hawaii and Puerto Rico donor hospitals
  • Ranking candidates with a non-exception MELD or PELD score above candidates with an exception MELD or PELD score when thescore and blood type compatibility is the same

Terms to know

  • Candidate: An individual on the organ transplant waiting list.
  • Donor Hospital: The hospital where the deceased or living donor is admitted.
  • Transplant program: An organ specific facility within a transplant hospital
  • Model for End-Stage Liver Disease (MELD): The scoring system used in allocation of livers to candidates who are at least 12 years old that is based on a combination of the candidate’s clinical lab values.
  • Pediatric End-Stage Liver Disease (PELD): The scoring system used in allocation of livers to candidates who are under 12 years old
  • Median Model for End-Stage Liver Disease at Transplant (MMaT): The MMaT for each transplant program is calculated by using the median of the MELD scores at the time of transplant of all recipients at least 12 years old who were transplanted at hospitals within 250 nautical miles (NM) of the candidates listing hospital in a 365-day period.
  • Match run: A process that filters and ranks waiting list candidates based on donor and candidate medical compatibility and organ-specific allocation criteria.
  • Classification: A collection of potential transplant recipients grouped by similar characteristics and within a given geographical area. Classifications are used to rank potential recipients of deceased or living donor organs.
  • Click here to search the OPTN glossary

eye iconComments

Derek Ginos | 01/25/2021

I am writing in support of this change to MMaT calculation around the donor hospital. The current policy penalizes programs who are utilizing marginal organs and working efficiently with OPOs to recover and use livers thus bringing down their medial MELD relative to other transplant programs within the same allocation radius. Although supporters of the current policy argue that this disparity will normalize over time, this assumes the differences in MELD are solely due to gaps in organ allocation from DSAs. However, COIIN and other studies have shown individual transplant program behavior can drastically influence median MELD at a given program. Revising this policy will level the playing field and assure all patients have equal opportunity for transplant regardless of the center in which they are listed.

Terry Box | 01/25/2021

This modification addresses a significant unintended consequence of the original acuity circle allocation system. Continued monitoring to confirm the new method and sorting system has desired impact will be needed.

Anonymous | 01/28/2021

1) The liver system is already incredibly complex. This approach makes the system even more complex and opaque without any appreciable benefits for patients. 2) This proposal walks back some of the progress made from the current system. MMaT around the transplant hospital make more sense because then the MMaT can adjust to the supply/demand dynamics in that candidate's area. 3) Since all of the organs are moving to continuous distribution, where candidates will have varying scores, why is it important that all HCC candidates on a match run have the same MELD score? Wouldn't it be better for the committee to wait until they develop continuous distribution to address these issues in a more comprehensive manner?

Sarah Jane Schwarzenberg | 01/29/2021

The portion of this policy that I strongly oppose is the prioritizing of candidates without exception points over those with exception points when the MELD and blood types are equivalent. First, exception points are meant to offset the inadequacy of the MELD score, particularly for women and children, who are disadvantaged by the MELD calculation. In particular, children scored under the MELD system are at substantial disadvantage, and exception points are the only means of equalizing their opportunity for transplant with that of adults. Removing their exception points during prioritization is not only medically inappropriate, but will reduce the number of children over age 12 years receiving liver transplantation. I strongly suggest that children age 12-18 be excepted from the policy of prioritizing non-exception points above exception points. Otherwise, the policy simply seems to inject more confusion into an already confusing system.

Anonymous | 02/03/2021

What is the justification for placing "non exception" candidates before exception candidates? After all the work that the Liver Committee has done to adjust exception scores and the NLRB, one has to question why they continue to punish candidates with exception scores.

Region 4 | 02/04/2021

Region 4 sentiment: 4 strongly support; 9 support; 5 neutral/abstain; 2 oppose; 0 strongly oppose. During the meeting there were comments voiced during the discussion, submitted online and submitted as comments from the OPTN representatives. Overall, there was general agreement and support for this proposal. Two commenters pointed out that when OPOs have centralized recovery centers it can add logistical complications when considering allocation and distance. There was also a comment that there needs to be more clarification about how this will affect pediatric candidates.

Shekhar Kubal | 02/05/2021

The current system has a major flaw by which it brings "geographic disparity" back to the liver allocation. The proposed change will address this issue to an extent. I strongly support this proposal.

Cody Reynolds | 02/06/2021

If exception points aren’t going to be taken into consideration, then why have exception points? My daughter has a PELD of 30 but has exception points because of poor weight gain, NG tube, and cholangitis infections. I sincerely hope there is a better plan that will be rolled out if this proposal is approved.

Cecile Aguayo | 02/11/2021

I oppose the proposal the necessitate ranking of calculated above exception scores because this change is being applied to children without specific consideration or modeling about how it will impact children. The Committee’s justification for this change is based entirely on data from adults, in whom calculated MELD is associated with higher risk of waitlist mortality than exception MELD. The committee cites NO evidence that children with calculated PELD/MELD scores are at higher risk than those with exception scores—OR that children with exception PELD/MELD scores are at LOWER risk than adults with calculated MELD scores. In fact, the opposite is true in children. Recent analyses of UNOS data show that: o In children, calculated PELD/MELD scores significantly underestimate waitlist mortality for children awaiting liver transplant. o More than 40% of children listed for liver transplant require MELD/PELD exception scores to appropriately reflect their risk, and to access transplant. o To equalize age-adjusted mortality of children and adults on the liver waitlist, a revised PELD score based on recent UNOS data had to add 9.4 points to children’s scores—suggesting that children’s current calculated PELD/MELD scores drastically underestimate their waitlist risk relative to adults’ calculated scores. This proposal will reduce children’s access to adult deceased donor livers and possibly pediatric donor livers. Adults are more likely than children to have high calculated MELD/PELD scores. Children often rely on exception PELD/MELD scores to compete with adults for adult donor livers. It will likely decrease the overall number of liver transplants, and significantly reduce split liver transplants: Offers of adult donor livers to children trigger almost all split liver transplants—creating 2 liver transplants from 1 liver. The Liver and Pediatric Committees are actively working on a PELD score revision. This PELD revision directly aims to increase utilization of calculated PELD scores and reduce reliance on exception scores. This is the first update to PELD calculation in 20 years. The MELD score for adolescents has never been validated or updated, and was derived based on adult data originally. This helps explain why the calculated scores are not adequate for ranking children on the liver waitlist, particularly when compared to adults. As we await this update to pediatric scoring, ranking adults with calculated MELD scores above children with exception MELD/PELD scores could substantially disadvantage children—decreasing their access to transplant and potentially increasing waitlist mortality for this vulnerable group. This proposal is not supported by any evidence as appropriate for pediatric candidates

Region 3 | 02/18/2021

Region 3 sentiment: Strongly support - 4, Support-12, Neutral/abstain - 6, Oppose -0, Strongly Oppose -0. During the meeting there were comments voiced during the discussion, submitted online and submitted as comments from the OPTN representatives. There was general support for this proposal. A member asked how the Donor Hospital calculation works for those donors that are transferred to an Organ Recovery Center, which may be located a significant distance from the original donor hospital, and it was clarified that the calculation would be based on the donor hospital. Another member said that this is a good step and that the current method needs to be changed.

Benjamin Philosophe | 02/18/2021

This would be a vast improvement over what we have currently. The MMAT-3 was created to provide equity for HCC patients. The irony however is as the new allocation for livers rolled out, this had the opposite effect, where HCC points varied amongst centers competing within a concentric circle. This proposed change will level out the playing field for tumor patients awaiting transplantation.

Benjamin Philosophe | 02/18/2021

This would be a vast improvement over what we have currently. The MMAT-3 was created to provide equity for HCC patients. The irony however is as the new allocation for livers rolled out, this had the opposite effect, where HCC points varied amongst centers competing within a concentric circle. This proposed change will level out the playing field for tumor patients awaiting transplantation.

Region 5 | 02/19/2021

Region 5 sentiment: 6 strongly support, 12 support, 8 neutral/abstain, 5 oppose, 4 strongly oppose. During the meeting there were comments voiced during the discussion, submitted online and submitted as comments from the OPTN representatives. Overall, there was general agreement and support for this proposal. One member commented that the pediatric community is concerned that this proposal was not designed with pediatric candidates in mind and the reasons they get exceptions. The proposal mentions no pediatric data at all. The member thinks it is important that pediatric candidates get exceptions for different reasons than adults. They do not see why pediatric candidates with pediatric end-stage liver disease scores (PELD) need to have exception scores below lab score candidates when median PELD at transplant (MPaT) is national. Another member agreed that children under two still have the largest waitlist mortality and the teenagers have some of the longest waiting times because of their creatinines and the disparity created. It sounds like we would be ranking children (teens) with exception PELD/MELD below adult calculated scores, is that correct? It looks like this would decrease splits, which helps both kids and adults in our region. Another member commented – as an example a teen with primary sclerosing cholangitis (PSC) will not get the same MELD as an adult with the same diagnosis. They think what gets confusing is that teens get automatic exceptions (which they do not). So we do not give them priority as originally discussed when the concentric circles allocation was being developed. The percentage of teenagers is very small. Would the Liver Committee consider placing teens above adults before exceptions? This should not affect the number of adult liver transplants. Could this be brought back to the committee? One member asked how is the committee going to address the changes being applied to children without specific consideration or modeling about how it will impact children on the waiting list?

regino gonzalez-peralta | 02/19/2021

The reason for allocating exceptions points between adults (mostly cancer) and children (mostly complications of liver disease) are vastly different. There are also many more adults listed for any one MELD score than are children. Thus, ranking adults with natural MELD over children with exception MELD would potentially make it more difficult for children-adolescents to receive organs and lead to increased pediatric waitlist mortality.

Debbie Nemeth | 02/26/2021

As a live liver donor and a spouse to a liver graft recipient, who was told he would die from his symptoms (symptoms similar to Primary Sclerosing Cholangitis, which we were told could only be cured through a liver transplant) before his MELD score reached the height required to receive a cadaver liver, since the MELD score calculation made no exception for his symptoms, I am in strong support for updating the liver allocation requirements to making an exception to the MELD score for patients with Primary Sclerosing Cholangitis and similar diagnosis. To be told your extremely debilitating, life altering and likely deadly symptoms can only be cured/improved by a liver transplant and that your spot in line for that liver transplant depends solely on a MELD score that does not take your specific symptoms/diagnosis into consideration is the equivalent of being told, "There is a solution for you, but because the system doesn't recognize you, there's no hope for you and you'll likely die." This should not be. As we grow in knowledge, we should be improving our system and our process. Given what we know now, the liver allocation process should start considering and providing exceptions for diagnosis that can only be cured/drastically improved by a liver transplant outside of what the current MELD score process accounts for. No longer is it simply one's bilirubin, creatinine, INR and sodium levels that determine an urgent need for a liver transplant. There are other factors and other symptoms that are just as deadly and equally can only be resolved through a liver transplant and we MUST start considering and making exceptions for those, too. This is personal for me and for so many individuals and their loved ones in this position. When we know better, we should do better. And we need to start considering and providing exceptions for things outside the basic "bilirubin, creatinine, INR and sodium" counts.

Anonymous | 02/27/2021

My 35 year old son was diagnosed at 21 with PSC. He’s now married and a father of two young children. As the progression is different with everyone, he’s had ups and downs until the past few months and now his PSC is progressing rapidly despite treatments and meds. He will more than likely be listed soon and I am asking that exception points for PSC be highly considered. These are strong people with an autoimmune disease who have done nothing to destroy their livers. Please make this change!