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Continued Review of National Liver Review Board (NLRB) Guidance

eye iconAt a glance

Current policy

When a liver transplant program believes that a candidate’s calculated model for end-stage liver disease (MELD) or pediatric end-stage liver disease (PELD) score does not accurately reflect their medical urgency for transplant, they can submit a request for a MELD or PELD exception score. The National Liver Review Board (NLRB) reviews requests from transplant programs for these exception scores. The NLRB uses policy and guidance documents to decide whether to approve or deny exception score requests. Since implementation in 2019, the OPTN Liver and Intestinal Organ Transplantation Committee has regularly evaluated the NLRB to identify opportunities for improvement.

Supporting media


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Proposed changes

  • Create guidance for pediatric liver transplant candidates with cystic fibrosis
  • Update guidance for adult liver transplant candidates diagnosed with hepatic adenomas and Budd Chiari syndrome

Anticipated impact

  • What it's expected to do
    • Provide NLRB members with updated guidance to use when reviewing MELD and PELD exception requests for specific candidates
    • Make it more likely that pediatric patient with liver disease related to cystic fibrosis and adult candidates with hepatic adenomas or Budd Chiari syndrome are able to access liver transplant in a timely and equitable manner.
  • What it won't do
    • Will not impact how liver candidates are prioritized on a match run

Terms to know

  • Guidance Documents: Documents that provide more information to transplant programs and NLRB members to use when making decisions on exception requests
  • Model for End-Stage Liver Disease (MELD): The scoring system used in allocation of livers to candidates who are at least 12 years old
  • Pediatric End-Stage Liver Disease (PELD): The scoring system used in allocation of livers to candidates who are under 12 years old
  • National Liver Review Board (NLRB): A review board of members drawn from a nationwide pool of liver transplant physicians and surgeons, who review exception requests from transplant programs for candidates whose automatically calculated model for end-stage liver disease (MELD) score or pediatric end-stage liver disease (PELD) score does not accurately reflect the candidate’s medical urgency for transplant.
  • Hepatic adenomas: Rare benign nodules in the liver
  • Budd Chiari syndrome: Medical condition in which the veins that drain the liver (hepatic veins) are blocked or narrowed by a mass of blood cells (clot), causing the blood to back up into the liver.
  • Cystic fibrosis: A genetic disorder that can lead to chronic damage in several organs including the lungs, pancreas, and liver.

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Provide feedback

eye iconComments

Anonymous | 08/06/2022

We are requesting a modification of the MELD score process. Genetic abnormalities ie alpha 1 antitrypsin protein deficiency has caused my husbands HCC. His cancer is limited to his liver, he has gone through various cancer treatments and his cancer is under control and Alpha one only affected his liver. He is in good shape good BMI and works out daily. His meld is 10. He will not be able to regenerate his liver due to Alpha 1. His cancer will come back its only a matter of time due to his cirrhosis due to the Alpha 1 Why can't he get points on the MELD SCORE for the genetic disease Alpha 1.