National Liver Review Board (NLRB) Guidance for Multivisceral Transplant Candidates

At 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. This proposal seeks to create NLRB guidance for multivisceral transplant (MVT) candidates so they can access higher MELD scores. MVT candidates have experienced reduced access to transplant and an increased risk of being removed from the waitlist for death or too sick for transplant since the implementation of the acuity circles policy. Guidance specific to MVT will allow a clear pathway for transplant programs to submit exception requests to the NLRB for MVT candidates, thereby increasing access to transplant and reducing waitlist mortality.

Supporting media

Presentation

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Proposed guidance

Adult candidates listed for multivisceral transplant should be considered for an initial MELD exception score equal to Median MELD at Transplant (MMaT) +6
Adult candidates listed for multivisceral transplant should be considered for an additional 3 point increase every 90 days they remain on the waitlist
Transplant programs must indicate the reason the candidate requires a liver transplant when submitting the exception request

Anticipated impact

What it's expected to do
- Increase access to suitable donors for MVT candidates on the waiting list
- Reduce waiting list mortality for listed MVT candidates

What it won't do
- Multivisceral transplant candidates will not receive an increased exception score if the reason they require a liver transplant is solely for immunological purposes

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
Multivisceral transplant candidate: Candidate who needs a liver-intestine-pancreas, liver-intestine, liver-intestine-kidney or liver-intestine-pancreas-kidney from the same donor
Acuity circles policy: A policy for allocating deceased donor livers using a series of concentric circles originating from the donor hospital