A liver candidate receives either a priority status or MELD¹ or, if less than 12 years old, a PELD² score that is used for liver allocation. The score is intended to reflect the severity of the candidate’s disease. When the calculated score or status does not reflect the candidate’s medical urgency, a liver transplant program may request an exception. Currently there is not a national system that provides equitable access to transplant for liver candidates whose status or calculated MELD or PELD score does not accurately reflect the severity of their disease. Instead, each region has its own review board that evaluates exception requests submitted by the liver transplant programs in its region. Most regions have adopted independent criteria used to request and approve exceptions, commonly referred to as “regional agreements.” Some have theorized that regional agreements may contribute to regional differences in exception submission and award practices, even among regions with similar organ availability and candidate demographics.^3,4,5

The Liver Committee previously distributed a proposal to establish a national liver review board (NLRB) in January 2016.⁶ Through policy and revised operational guidelines, this proposal incorporates feedback received during the first round of public comment to establish a national structure for review of MELD and PELD exception cases. The NLRB seeks to mitigate regional differences in award practices by establishing new voting procedures and giving the Committee the ability to develop national guidance for assessing common requests, which supports Goal 2 of the OPTN Strategic Plan.⁷ This proposal also improves the efficiency of the review board system by reducing the overall workload for reviewers and eliminating unnecessary delays in awarding exception points when appropriate.

Finally, this proposal modifies the way in which the value for exception points is determined and assigned. To achieve more nationwide uniformity in the value of exception scores awarded to candidates for standardized exceptions, the Committee proposes setting the points assigned to adult candidates to a fixed value just below the median MELD at transplant for adult recipients within the Donation Service Area (DSA). For candidates between 12 to 17 years old, the points value would be tied to the median MELD at transplant for all liver recipients in the DSA. And for pediatric candidates less than 12, the points value would be tied to the median MELD at transplant for all liver recipients in the region. This change serves a secondary goal of addressing the ever-increasing rise in median MELD at transplant, otherwise known as MELD inflation.

1. Model for End-Stage Liver Disease
2. Pediatric End-Stage Liver Disease
3. Argo, C. K., G. J. Stukenborg, T. M. Schmitt, et al. “Regional Variability in Symptom‐Based MELD Exceptions: A Response to Organ Shortage?” American Journal of Transplantation, 11(2011), 2353-2361.
4. Massie, A. B., B. Caffo, S. E. Gentry, et al. “MELD exceptions and rates of waiting list outcomes.” American Journal of Transplantation, 11(2011), 2362-2371.
5. Rodriguez-Luna, H., H. E. Vargas, A. Moss, et al. “Regional variations in peer reviewed liver allocation under the MELD system.” American Journal of Transplantation, 5(2005), 2244-2247.
6. https://optn.transplant.hrsa.gov/media/1242/07_national_liver_review.pdf
7. https://optn.transplant.hrsa.gov/governance/strategic-plan/