Executive Summary

The MELD¹ or, if less than 12 years old, PELD² score is used for liver allocation. The score is intended to reflect the candidate’s disease severity, or the risk of three-month mortality without access to liver transplant. For some patients the risk of death without access to liver transplant is not accurately predicted by the MELD score. In these instances, the liver transplant program may request an exception score.

Most OPTN/UNOS regions have adopted independent criteria used to request and approve exceptions, commonly referred to as “regional agreements.” These 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}

The OPTN/UNOS Liver and Intestinal Organ Transplantation Committee is currently pursuing the establishment of the National Liver Review Board (NLRB) to promote consistent, evidence-based review of exception requests. In support of this project, the Committee has developed guidance for specific clinical situations for use by the NLRB to evaluate common exceptional case requests for adult candidates with ten diagnoses, not all of which are appropriate for MELD exception. This supplements existing national guidance and replaces the regional agreements. Review board members and transplant centers should consult this resource when considering MELD exception requests.

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?” Am J Transplant, 11(2011): 2353-2361.
4. Rodriguez-Luna, H., H.E. Vargas, A. Moss, et al. “Regional variations in peer reviewed liver allocation under the MELD system.” Am J Transplant, 5(2005): 2244-2247.

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