8/31/2023 0 Comments Meld liver transplantSince 1998, patients with HCC within UNOS criteria have been eligible for upgraded priority, and since the inception of MELD-based allocation in 2002, Milan criteria became UNOS criteria, and waitlist candidates with HCC within criteria were awarded standardized exception points to increase waitlist priority, with the intended goal of expediting transplantation before tumor burden exceeded criteria, thus compromising post-transplant outcomes. Prior to the implementation of MELD-based allocation, post-transplant outcomes in patients with HCC were suboptimal. Specifically, the best post-transplant outcomes were seen in recipients with one tumor ≤5 cm in diameter, or 2–3 tumors, each ≤3 cm (Milan criteria). In the nascent years of liver transplantation, it was recognized that the number and size of lesions in a transplant recipient were strongly associated with post-transplant outcomes. The most common indication for MELD exception points is HCC. In this article, we will review the current state of MELD exceptions, focusing on the most common indications for exception points, highlight the current challenges of the MELD exception system, and discuss future directions or improvements in the system.įull size image Standardized Hepatocellular Carcinoma (HCC) Exception Points In fact, in recent years, over one-third of transplant recipients had received exception points, with nearly two-thirds having an exception for HCC within Milan criteria (Fig. Over time, there has been a continuous increase in the number of waitlist candidates with MELD exception points, for both standardized and non-standardized exceptions. For exceptions that do not receive automatic approval, and require a vote by the RRB, the application may be approved or denied, with centers having the option of appealing a denial, and/or resubmitting with fewer requested exception points. Each RRB is expected have representation from hepatology and surgery, and can also include non-transplant healthcare providers, and/or non-medical (public) representatives, although in practice this occurs infrequently.ĭecisions on approval or denial of exceptions, and the policies for approving exceptions vary by conditions, and will be discussed below. As some regions comprise a very large number of centers, certain RRBs rotate membership. Each RRB is chaired by the Regional representative to the Liver/Intestine committee, and while each active liver transplant program has the opportunity to be represented, the number of members of an RRB varies by region. There are guidelines to help govern the composition and structure of each RRB, although each region has discretion as to how the RRB is set up. Within each United Network for Organ Sharing (UNOS) region, a regional review board (RRB) is charged with reviewing and approving applications for exceptions. By contrast, non-standardized exceptions are those conditions which are deemed important by the transplant team but for which the risk of mortality is not as clear-cut, and thus require review on a case-by-case basis (i.e., cholangitis, refractory ascites, hyponatremia). Standardized exceptions are those conditions for which there are sufficient data to warrant allocating automatic exception points to patients meeting formalized exception criteria (i.e., hepatocellular carcinoma ). Since implementation, a system of exception points has been in place in order to award increased waitlist priority to those patients whose severity of illness or risk of complications are not captured by the MELD score, but may have equivalent mortality risk to those with higher MELD scores.īroadly speaking, MELD exceptions fall into two categories: (i) standardized exceptions, and (ii) non-standardized exceptions. There are some patients that may be ‘sicker’ than their MELD score, due to multiple complications of portal hypertension, inaccurate measurements of renal function due to a low creatinine from low muscle mass, or have complications of liver disease requiring timely transplant that are not captured by the MELD score. However, as is the case with any mathematical model or risk score, there is imperfect correlation between MELD score and waitlist outcomes. Prioritization on the waitlist is determined by a patient’s Model for End-Stage Liver Disease (MELD) score, a calculated risk score based on a patient’s bilirubin, creatinine, and international normalized ratio (INR) and has been validated to accurately predict a patient’s 3-month waitlist survival. Since February 27, 2002, allocation of livers to waitlisted transplant candidates has been based on an urgency-based disease severity model.
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