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Retaining Pediatric Priority for Liver Candidates with a MELD Score who are on the List after their 18th Birthday

Retaining Pediatric Priority for Liver Candidates with a MELD Score who are on the List after their 18th Birthday

Attn: Liver Transplant Programs

Review your options available to retain pediatric priority for your liver candidates who were registered before their 18th birthday and who remain on, or have returned to, the waiting list after they turn 18 years of age. 

Pediatric Classification Exception Process
Once a liver candidate with a MELD score turns 18, they are no longer classified as a pediatric candidate. The classification change does not impact the candidate’s MELD score; however, it could impact that candidate’s prioritization for pediatric donor livers.
Liver Program Scenario: One of your transplant candidates is 18 years or older and was placed on the waiting list before his 18th birthday. Your program believes he would be served more appropriately if he were classified as a pediatric candidate; therefore, you need to submit to your regional review board (RRB) a MELD exception application requesting pediatric classification.

Your MELD exception application must:

  • request your candidate’s current MELD score and only address the pediatric classification change. (If you also believe that his MELD score requires an exception, you must submit a second MELD exception application so that the RRB can consider each issue separately. If the RRB approves your MELD exception application that requests pediatric classification, then no additional MELD exception applications to request pediatric classification are necessary.)
  • have “Other” as the diagnosis and “Pediatric Classification” in the “Other Diagnosis Specify:” field.
  • include a detailed narrative that explains the candidate’s situation and why the pediatric classification is more appropriate. See screen shot of how you should enter your MELD exceptions in UNet℠

If the RRB approves your candidate’s MELD exception application requesting pediatric classification, UNOS staff will modify that candidate’s record.

Important:  this process does not apply to Status 1A and Status 1B candidates registered before their 18th birthday. Per the definition in Policy 3.6.4.2, Status 1A and Status 1B candidates who have turned 18 years of age and were listed prior to their 18th birthday, continue to be classified as pediatric candidates and can qualify under pediatric Status 1A and Status 1B criteria.

Background
The OPTN/UNOS Pediatric Transplantation Committee (the Committee) discussed Policy 3.6.4.2 (Pediatric Candidate Status.) at its April 2013 meeting. The Committee’s discussion focused on the following excerpt from Policy 3.6.4.2:

“A candidate who does not have a risk of candidate mortality expressed by the PELD or MELD score that, in the judgement of the candidate’s transplant physician, appropriately reflects the candidate’s medical urgency or was listed at less than 18 years of age and remains on or has been returned to the Waiting List upon or after reaching age 18 may nevertheless be assigned to a higher or the appropriate PELD or MELD score and pediatric classification (for candidates listed at less than age 18 who turn age 18) upon application by his/her transplant physician(s) and justification to the applicable Regional Review Board that the candidate is considered, by consensus medical judgement, using accepted medical criteria, to have an urgency and potential for benefit comparable to that of other candidates having the PELD or MELD score.”

Committee discussion revealed confusion about this policy and it decided that UNOS should provide the transplant community with additional education on it.

If you have any questions, please contact your regional administrator at (804) 782-4800.

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