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Enhancements to the National Liver Review Board

Proposal Overview

Status: Public Comment

Sponsoring Committee: Liver and Intestinal Organ Transplantation

Strategic Goal: Promote the efficient management of the OPTN

Read the proposal (PDF; 01/2020)

Contact: Betsy Gans

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eye iconAt a glance

What is current policy and why change it

When a transplant program believes that a liver candidate’s model for end-stage liver disease (MELD) or pediatric end-stage liver disease (PELD) score does not accurately reflect the candidate’s medical urgency, they may request a MELD or PELD score exception. The National Liver Review Board (NLRB) is responsible for reviewing exception requests and either approving or denying the requested score. Since implementation, the transplant community and the OPTN Liver and Intestinal Organ Transplantation Committee (Liver Committee) have noted numerous ways to improve the NLRB in its goal to provide more efficient and equitable access to transplant.

What’s the proposal?

  • To improve the NLRB by:
    • Automatically granting extension requests for Hepatocellular Carcinoma (HCC) candidates, as long as they meet the standard extension criteria and are requesting a policy-assigned score.
    • Clarifying the update schedule for median MELD at transplant and median PELD at transplant.
    • Updating operational guidelines to include:
      • Language instructing review board members on how to evaluate candidates with unique situations.
      • Adjusted threshold for removing inactive reviewers.
      • Clarification that the Liver Committee may delegate authority for final appeal review to a subcommittee.
    • Updates to guidance documents to include:
      • Recommendations for secondary sclerosing cholangitis (SSC) and adults with metabolic disease.
      • Removing unnecessary language for portopulmonary hypertension (PH).
      • Clearer guidance for handling candidates with history of hepatocellular carcinoma (HCC).

What’s the anticipated impact of this change?

  • What it’s expected to do
    • Make the NLRB more transparent, efficient, and equitable.
    • Increase transparency in the update schedule of score changes.
    • Increase the likelihood that candidates with similar clinical characteristics are treated in a similar fashion.
  • What it won’t do
    • Will not impact any specific patient group such as pediatric candidates, minority candidates, sensitized candidates, or living donors.
    • There is no anticipated negative impact for any group.

Themes to consider

  • MELD or PELD score recommendations in guidance documents
  • NLRB voting thresholds
  • How to improve the NLRB system

Terms you need to know

  • MMaT: Median Model for End-Stage Liver Disease (MELD) at Transplant. The NLRB awards exception points for candidates 18 years or older relative to the MMaT for the area where the candidate is listed. This ensures that exception candidates are assigned scores that reflect the candidate pool in the area that they are listed.
  • MPaT: Median Pediatric End-Stage Liver Disease (PELD) at Transplant. The NLRB awards exception points for candidates less than 18 years old relative to the MPaT for the nation. This ensures that pediatric exception candidates are assigned scores that reflect the pediatric candidate population across the nation.
  • Exception Points: Additional points added to a MELD or PELD score for a candidate by the NLRB to more accurately reflect the candidate’s medical urgency.
  • Click here to search the OPTN glossary.


Anonymous | 02/07/2020

As a family member of a liver transplant recipient who received MELD exception points for the presence of hepatocellular carcinoma, I believe that enhancements to the National Liver Review Board will help to ensure that the MELD score reflects the candidate's condition and need for transplant and that this is done in a fair and consistent manner.

OPTN Region 4 | 02/08/2020

Strongly support (3), Support (17), Neutral/Abstain (1), Oppose (0), Strongly Oppose (0) Comments: Region 4 supported this proposal. Those in attendance agreed that this would improve the NLRB. During the discussion some members commented that while meeting the criteria established for each diagnosis is important, review board members need to follow the criteria and not impose medical judgement.

Anonymous | 02/13/2020

I believe strongly that the liver transplants should remain within the 250 mile radius (as long as it is in USA). The central US has the most percentage of organ donation notations on drivers licenses and should be awarded for that service to their fellow men/women that they intend to assist.

OPTN Region 6 | 02/18/2020

Strongly support (2), Support (13), Neutral/Abstain (1), Oppose (0), Strongly Oppose (0) The region supported the proposal. Members offered a variety of feedback in response to the questions asked. They thought inactive reviewers should be assessed more frequently – suggestion of every 6 months instead of 12 months. Inactive reviewers should be removed from the NLRB. Exception requests often do not follow the exception guidelines, so there was a suggestion to have guidelines easily accessible to people submitting exceptions. Since exception narratives are often lengthy and hard to follow, a member suggested shortening the narrative to a timeline of events and facts. There was general consensus that SSC guidance should mirror PSC guidance. In the breakout, there was consensus that MMaT-3 is an appropriate score for adults with metabolic disease. In the main meeting, a member asked whether MMaT-3 makes sense for pediatric patients when they become adults. In addition, there was a comment about that fact that we are now sharing liver organs in a 500 nautical mile circle based on MELD score, however our Region 6 centers designated MMaT determined by the MELD score within a 250 nautical mile nautical circle – this appears to be unjust. Portland transplant centers – Oregon Health and Science University and VA Portland Health Care System have a MMaT of 32 which is equal to the San Francisco programs’ MMaT, and hence the sharing MELD threshold, however, when determining the MELD scores for MELD exceptions – we are ,mandated to use the MMaT within 250 nautical miles – Seattle centers have a MMaT of 31 – hence, the Oregon liver transplant candidates lose a point for MELD exceptions (MMaT of 31), however, they share their liver organs based on MMaT with San Francisco programs, which is 32. This issue needs to be addressed.

OPTN Region 8 | 02/18/2020

Liver & Intestinal Transplantation Committee: Enhancements to National Liver Review Board • 80% of HCC exceptions were approved which tells us the auto approval is not granular enough • Support for 5% threshold for removal • Support for treating SSC and PSC the same • Adults with metabolic disorders should have the option to request additional MELD exception points. These patients are not all equal and some are at higher risk. Vote: 5 Strongly Support, 14 Support, 3 Neutral/Abstain, 0 Oppose, 0 Strongly Oppose

Region 5 | 02/21/2020

Strongly support (5), Support (21), Neutral/Abstain (2), Oppose (0), Strongly Oppose (0) Comments (include discussion during breakouts and general session): Region 5 supported this proposal. Members raised a few questions regarding the review and appeal process. • If a review is appealed and approved upon appeal, there should be training for the original reviewers • Subcommittee to review appeals needs appropriate representation from the three NLRB review boards.

Anonymous | 02/28/2020

2 Strongly Support, 16 Support, 6 Neutral/Abstain, 0 Oppose, 0 Strongly Oppose Members of Region 2 supported the proposal. One member commented that it would be helpful if there was an opportunity for reviewers to get answers to questions on an exception request before having to vote. Often times it is a simple clarification and it could save time to get an answer instead of denying the request. Another member commented that there needs to be additional clarification about HCC candidates who are listed, drop off for a period of time, and then get re-listed. Lastly, one member commented that it is confusing when listing an exception that the requesting program has to submit a specific MELD score but the review board only sees the MMaT -3. For consistency, the requesting program should also see the MMaT -3.