The National Liver Review Board (NLRB) and the new liver distribution system based on acuity circles will go into effect on the same date – April 30, 2019. On that date, most candidates with an existing MELD or PELD exception score will have their scores converted according to the criteria in the new policy (see below for further details on conversion).
Implementation of the NLRB, originally scheduled for January 31, was postponed to seek public comment on a potential transition period for implementation. This issue was prompted by the potential for disadvantage to some exception candidates in the time frame between implementation of the NLRB and of the new distribution system.
The OPTN Liver and Intestinal Organ Transplantation Committee reviewed public input, as well as data on liver candidates who have current exception scores. The committee concluded that the best option is to combine implementation of NLRB and the new liver distribution policy, as well as to convert most candidates with exceptions at the time of implementation to the new exception score criteria set forth in policy.
Doing so will allow liver transplant programs more time to prepare for the new system and communicate with candidates who have exception scores. A conversion of most exception scores as of implementation will also eliminate two potential problems that could unduly advantage or disadvantage exception candidates:
- Candidates with the same medical condition could have different existing exception scores, granted or extended at different points in time, remaining in the new system for a period of months; and/or
- Depending on when an exception or extension was approved prior to implementation, candidates converted during a transitional period to the same exception score could still have different credit for time waiting in status compared to one another
The Liver and Intestinal Organ Transplantation Committee presented these recommendations for implementation to the OPTN Executive Committee, which approved them at a conference call held March 26, 2019.
Exception score conversion plan
As of system implementation April 30, liver transplant candidates with existing exception scores will have their scores converted as follows.
| Candidate age | Diagnosis | Current exception score | Exception score after conversion |
| At least 18 at registration | Any | 40 | 40 |
| At least 18 at registration | Any (except primary hyperoxaluria) | 22-39 | MMaT-3 |
| At least 18 at registration | Primary hyperoxaluria | 22-39 | MMaT |
| At least 18 at registration | Any | Less than 22 | No change to score |
| At least 12, and less than 18 at registration | Any | 40 | 40 |
| At least 12, and less than 18 at registration | Any (except primary hyperoxaluria) | 22-39 | MMaT |
| At least 12, and less than 18 at registration | Primary hyperoxaluria | 22-39 | MMaT+3 |
| At least 12, and less than 18 at registration | Any | Less than 22 | No change to score |
| Less than 12 | Any | 40 or higher | No change to score |
| Less than 12 | Any (except primary hyperoxaluria) | Less than 40 | MPAT |
| Less than 12 | Primary hyperoxaluria | Less than 40 | MPat+3 |
If the transplant program has submitted an exception form as of the implementation date, but the regional review board had not acted on the request, the same rules for conversion will apply as for the approved forms, and the pending form will be routed to the NLRB for approval. The Liver and Intestinal Organ Transplantation Committee strongly recommends that any new exception requests prior to April 30 be submitted more than one week in advance of that date, to reduce the initial number of requests that will need to be routed to the NLRB.
Resource and training information
Resources in the liver implementation toolkit will be updated to reflect the implementation details.
There are two educational opportunities for liver and intestinal organ allocation coming soon through UNOS Connect. These are:
- a learning module and interactive guide to policy
- a live town hall event scheduled for April 18. You may now register for the town hall via UNOS Connect.
Two additional webinars are being scheduled prior to policy implementation. One will be held Monday, April 15, for any interested participants; the other will be held Wednesday, April 17, for members of the NLRB and regional liver review board. Times and registration information for those webinars will be provided as soon as they are available.
