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Assessing liver transplant candidates’ level of illness

The national liver allocation system is designed to consider all transplant candidates in an equitable and consistent manner, understanding that there are currently not enough organs to transplant all in need. Liver allocation policy is developed with extensive input from the public and the community of donation and transplantation professionals.

Recent public attention has focused on the process of determining medical urgency for liver transplant candidates, especially those whose medical circumstances require special attention. While the OPTN cannot comment on any individual candidate’s medical history or status, we hope the following information clarifies how candidates receive transplant priority based on their level of illness.

For most liver transplant candidates, medical urgency is determined by an evidence-based formula, either MELD for candidates age 12 and older or PELD for those younger than 12. Each formula uses objective medical data to assess how likely a person may survive in the short term without a liver transplant.

Some transplant candidates have a medical condition, such as cancer or rare forms of chronic liver disease, where MELD or PELD will not accurately predict their short-term transplant need. If so, they may qualify for an “exception” score – a separately assigned score to be used instead of their calculated MELD or PELD in matching the person for available organ offers.

Some medical conditions are common enough that the liver transplant candidate can get a standard exception score. The person’s medical condition would need to meet criteria outlined in OPTN policy.

Some candidates may be sicker than the standard exception score would indicate. In other cases, the person may have a condition that does not meet criteria for a standard exception score. In either instance, the transplant team treating the candidate may apply to a national review board of medical experts and request a customized exception score. The review board is tasked with deciding whether the requested score is reasonable based on the patient’s current medical condition and the likelihood that the recipient will do well once transplanted.

The national liver review board (NLRB) consists of volunteer medical experts who practice transplantation throughout the United States. It considers all exception requests on an anonymous basis, with no information about the candidate’s identity or the hospital making the request. The board makes its decision based solely on the medical facts supplied by the transplant hospital, aided by their own medical judgment and guidance from the OPTN. The review board may grant or deny the exception score requested.

If the initial request is denied, the transplant team listing the candidate can choose to pursue a series of up to three appeals. The transplant team would have the opportunity with the appeals to provide additional detail to clarify questions that may arise in earlier review. In each instance, the reviews are conducted based on the medical facts presented, the medical expertise of the reviewers and applicable OPTN guidance.