National liver review boardView comments
Status: Committee Review
Sponsoring Committee: Liver and Intestinal Organ Transplantation
Strategic Goal: Provide equity in access to transplants
A liver candidate receives a 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 does not reflect disease severity, a liver transplant program may request an exception score. Currently there is not a national system that provides equitable access to transplant for liver candidates whose 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 In November 2013, the OPTN/UNOS Board of Directors charged the Liver and Intestinal Organ Transplantation Committee with developing a conceptual plan and timeline for the implementation of a national liver review board.
Through policy and revised operational guidelines, this proposal establishes a national structure for review of MELD and PELD exception cases in which all liver transplant programs have an equal opportunity for representation. The National Liver Review Board 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.6 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.
See “Continued Policy Development” under “How was this proposal developed?” for more information.
- Model for End-Stage Liver Disease
- Pediatric End-Stage Liver Disease
- 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.
- 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.
- 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.
This proposal was available for public comment in January 2016.
A revised proposal was available for public comment in January 2017.
The Committee considered changes to the number of points assigned to exception candidates. To assist them in further developing this proposal for a second round of public comment, the Committee requested feedback on whether it is appropriate to:
Award exception candidates one or two MELD points below the median allocation MELD at transplant for the candidate’s Donor Service Area (DSA).
Remove the automatic three-month increases in standardized exception scores, also referred to as the “MELD elevator.”