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National liver review board is implemented

The OPTN launched a National Liver Review Board (NLRB) on May 14 to improve the process of assessing and determining liver transplant priority for candidates with exceptional medical conditions.  It is intended to increase consistency in providing exception scores nationwide and better balance transplant access for candidates with and without exception scores.

Most liver transplant candidates receive an allocation score based on either the Model for End-Stage Liver Disease (MELD) or the Pediatric End-Stage Liver Disease (PELD) model.  These scores estimate candidates’ short-term risk of death without receiving a liver transplant. 

While MELD and PELD provide reliable estimates for most liver candidates, others have less common diseases or complications that the formulas do not capture as well.  These candidates receive an “exception score” comparable to the degree of illness of MELD and PELD candidates.

The NLRB replaces the individual review boards previously used in each of the 11 OPTN regions.  Reviewers are drawn from a nationwide pool of liver transplant physicians and surgeons, who will review exception requests on an anonymous basis for candidates not listed at the transplant program of any of the reviewers.  The reviewers will consider medical guidelines intended to enhance consistency in how exception scores are decided.

The policy also establishes standard allocation point thresholds for a number of common medical conditions needing an exception score, as well as guidance documents for NLRB members to consult when considering a non-standard exception.  The most common conditions that result in exception scores will be compared to the median MELD or PELD score at transplant for the area surrounding the transplant hospital. A median is the statistically calculated “midpoint” score over a range of all recently performed transplants.  This comparison will allow exception scores to be more reflective of the range of candidates’ medical urgency at their transplant hospital and at other transplant hospitals within a distance of 250 nautical miles.

Most candidates with existing exception scores as of [date TBD] will have their score converted at that time to the new criteria. Some exception scores that are considerably higher or lower than most median scores will stay the same until those scores expire or need to be renewed.

Also on May 14, the OPTN implemented a new system of liver distribution to improve the equity of access to liver transplantation for candidates nationwide. The new system replaces arbitrary distribution area boundaries with a more consistent process based on candidates’ medical urgency and the distance between the donor hospital and their transplant hospital.  This article describes the new distribution system.