Updates to National Liver Review Board Guidance and Further Alignment with LI-RADS

At a glance

Background

The National Liver Review Board (NLRB) reviews requests from transplant programs for Model for End-Stage Liver Disease (MELD) and Pediatric End-Stage Liver Disease Model (PELD) exception scores for candidates. Transplant programs may request exception scores when a candidate has a greater medical urgency for a transplant than indicated by their score. The NLRB uses guidance documents to decide whether to approve or deny exception score requests. The guidance documents provide recommendations for review board members and transplant programs on diagnosis and clinical situations that are not in OPTN policy. There are also standard diagnosis for exceptions in OPTN policy. These standard exceptions do not have to be reviewed by the NLRB. The OPTN Liver and Intestinal Organ Transplantation Committee regularly evaluates the National Liver Review Board guidance and policies to identify opportunities for improvement.

Supporting Media

Presentation

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Proposed guidance/policy

• Score recommendations will be added to each diagnosis in the two adult guidance documents, Adult Other and Transplant Oncology, to provide more standard requests and approvals
• The NLRB Operational Guidelines will be updated to ensure that exception requests for adult diagnosis not in policy are reviewed by the adult review board with the appropriate expertise
• Updates will be made to existing OPTN policy (9.5.i) to align requirements for Hepatocellular Carcinoma (HCC) standard exceptions with recommendations and terminology used by the American College of Radiology

Anticipated impact

• What it's expected to do
  • Provide NLRB reviewers and transplant programs with exception score recommendations for all diagnoses in the guidance documents
  • Provide an additional imaging option to diagnose HCC for MELD exceptions
  • Give patients information about what criteria is considered when centers request a MELD or PELD exception score
  • Create a more efficient and equitable system for reviewing MELD and PELD exception requests
  • Ensure that adult exception requests go to the review board with the appropriate expertise
  • Clarify policy to align with current practice and terminology

Terms to know

• Guidance Documents: Documents that provide information to transplant programs and NLRB members to use when making decisions on exception requests.
• Operational Guidelines: A document that outlines the representation on the NLRB, the responsibility of NLRB members, voting procedures and the appeals process for transplant programs when the NLRB denies an exception request.
• 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.
• Medical Urgency: Risk of death within three months on the liver waiting list.
• National Liver Review Board (NLRB): A review board of OPTN 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.
• Contrast-enhanced ultrasound (CEUS): A diagnostic tool used to detect a variety of diseases and conditions by using an intravenous agent that contains microbubbles that allows for the ability to see the flow of blood through organs and blood vessels.
• Liver Imaging Reporting and Data System (LI-RADS): A standardized terminology and classification system for imaging of HCC lesions.

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Read the full proposal (PDF)