Audience:
Liver transplant program directors, surgeons, physicians, administrators, clinical coordinators and data coordinators; compliance and quality managers; clinical support staff; OPO executive directors and procurement directors/managers
Implementation date:
April 30, 2019
At-a-glance
On April 30, 2019, both the National Liver Review Board (NLRB) and the liver distribution system based on Acuity Circles will begin operation.
The NLRB will replace the regional review system for considering and assigning exception MELD and PELD scores. The updated policy language to be effective upon implementation is available here.
The Acuity Circle distribution will replace donation service area (DSA) and regional boundaries currently used in liver distribution with a system based on distance between donor hospital and transplant hospital. This policy notice addresses details of the new policy.
The UNOS Secure EnterpriseSM system, which includes UNetSM and other transplant applications such as WaitlistSM, DonorNet®, TIEDI® and KPDSM, will be unavailable for a brief period the morning of April 30 to allow for implementation. This notice will be updated to specify when the down time will occur.
The NLRB will collect additional data for certain standard exceptions, allowing more exceptions to be automatically approved. Requests for custom exceptions will be considered in relation to the median score at transplant (median MELD at transplant (MMaT) for recent MELD recipients, calculated for transplants at hospitals within a limited area surrounding your transplant hospital; national median PELD at transplant (MPaT) for PELD recipient transplants).
As of the time of policy implementation, 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).
The liver distribution system will first prioritize livers from adult deceased donors for compatible Status 1A and 1B candidates listed at transplant hospitals within 500 nautical miles of the donor hospital. Following that, it will prioritize candidates of similar groupings of medical urgency within 150, 250 and 500 nautical miles from the donor hospital. Livers from deceased donors younger than age 18 will first be offered to any candidates younger than age 18, listed at any transplant hospital within a 500 nautical-mile radius of the donor hospital, before any adult candidates of the same level of medical urgency. Further information, including an animated illustration of the liver sequence, is available here.
What you should know about the NLRB
The NLRB will be comprised of three specialty boards: Adult HCC, Adult Other Diagnosis, and Pediatrics.
Every active liver transplant program may appoint a representative and alternate to each of the adult specialty boards. A liver transplant program with an active pediatric component may appoint a representative and an alternate to the pediatric specialty board.
Please be aware of the new guidance and educate your staff on the new scoring for standardized exception requests. Please also communicate with your candidates who have existing exception scores.
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.
What you should know about liver distribution
Based upon the distance between donor and transplant hospitals, the sequence of liver offers is likely to change in many areas. With the exception of offers made first to Status 1A/1B candidates and offers from pediatric donors, livers will first be offered for candidates of similar medical urgency within a 150 nautical mile radius before any more distant candidates of similar urgency receive offers.
Resources and upcoming webinars
- Various resources are available in the implementation toolkit.
- Access all the available policy and system trainings in UNOS Connect from the course catalog; Liver category*
- National Liver Review Board Policy: MELD/PELD Exception Scoring (LIV107)
- National Liver Review Board Policy: New Processes (LIV108)
- NLRB training for review board representatives (LIV109)
- Liver and Intestine Allocation (LIV110)
- A template view of the updated NLRB data forms are available on UNetSM. From Secure Enterprise, Select “Resources” from the dropdown menu, then “Forms/Tools,” then select “Reference Docs” in the left-hand menu.
- If you have previously accessed these resources, keep in mind that they have now been updated to reflect the NLRB conversion and any other details that may have changed.
- UNOS will host a live town hall event April 18, at 3:00 p.m. EDT. You may register for the town hall via UNOS Connect.
- UNOS is also scheduling two additional webinars prior to policy implementation. One will be held Monday, April 15, 2019, from 2:00 to 3:00 pm EDT. You may register online at this link.The other webinar will be held Wednesday, April 17, for members of the NLRB and regional liver review board; review board members will receive a separate invitation.
- Articles:
https://optn.transplant.hrsa.gov/news/national-liver-review-board-to-be-implemented-april-30/ - https://optn.transplant.hrsa.gov/news/optnunos-board-approves-updated-liver-distribution-system/
- https://optn.transplant.hrsa.gov/news/optnunos-board-approves-national-board-to-review-exception-priority-for-liver-transplant-candidates-guidance-document-for-transplant-candidate-education/
Additional resources: Online help documentation covering UNet functionality will be available when the system goes into effect. Access Secure Enterprise and then choose Waitlist. On the Help menu, click Waitlist Help. You may search for a specific help topic or use the table of contents to assist with your search.
Questions?
If you have questions about how to submit exception forms, contact UNOS Customer Service at 800-978-4334. For policy-related questions,
send an e-mail to [email protected].
