1. Liver and Intestinal Organ Transplantation Committee
Fall 2017

2. Recent Public Comment Proposals
Proposal to Establish a National Liver Review Board & corresponding guidance documents
Board of Directors approved in June 2017
2 post-public comment changes:
All candidates will receive the re-calculated median MELD at transplant score every 180 days (this was discussed by community during public comment)
Will exclude nationally shared livers from the MMaT score
Anticipated implementation - Summer 2018
In June 2017, the Board of Directors approved the proposal to establish a national liver review board, or NLRB after the last round of public comment. This proposal establishes a NLRB with 3 specialty boards: Adult HCC, Adult Other Diagnosis, and Pediatrics. Regional agreements will be eliminated when we implement this proposal. NLRB members will use the complementary NLRB guidance documents to assess the most common types of exceptions. The scores for standardized exceptions will be tied to the median MELD at transplant in the DSA.
There were 2 changes following public comment this Spring. As presented to the regions, the Committee favored updating all exception candidates with the re-calculated median MELD at transplant score every 180 days. The original proposed policy would have prevented a candidate’s score from going down shortly after it was awarded, if for example the median meld at transplant in the DSA decreases. However, the original proposed policy would have created a scenario where two candidates with the same diagnosis would have different MELD scores following the 6 month update. There was support from the community that all existing MELD exception candidates would receive the re-calculated MMaT exception score at the 180 day update. The post-public comment modification to the policy language reflects this sentiment of the Committee and regions.
The second post-public comment change included excluding transplants resulting from nationally shared livers in the median MELD at transplant calculation. The idea behind this amendment is that nationally shared livers are often utilized in low-MELD candidates. Therefore, the use of nationally shared livers in low MELD candidates will lower the MMaT in the DSA. In a scenario where one center in a DSA is aggressive in this practice, the MMaT score for exception candidates in the DSA will be effected by these transplants, even if other centers do not transplant nationally shared livers at the same rate. The region commented that the resulting effect on the MMaT score for exception candidates in the DSA may discourage the use of nationally shared livers. The Committee strongly agreed they did not want to propose a policy that would discourage utilization of nationally shared livers and agreed to exclude transplants resulting from nationally shared livers in the MMaT calculation.

3. Policy Implementation Dates
Changes to HCC criteria for auto approval
Board of Directors Approved – Dec. 2016
Summary of changes
Candidates within T2 but with AFP>1000 are not initially eligible for a standardized MELD exception
Eligibility criteria in policy for being included in the downstaging protocol
Implementation expected for 4th quarter 2017
Will provide educational material before implementation
The changes to HCC criteria for auto approval proposal was approved by the Board of Directors in December, This proposal contained two primary policy changes:
1) Candidates with lesions meeting T2 criteria but with an AFP greater than 1000 are not initially eligible for a standardized MELD exception. If these lesions fall below 500 after local-regional therapy, the candidate is eligible for a standardized MELD exception. Candidates with an AFP
level greater than or equal to 500 at any time following local-regional therapy will be referred to the review board.
2) The policy addition describes the eligibility criteria for being included in the downstaging protocol. Candidates meeting the criteria will be eligible for automatic priority after they’ve had local regional treatment, and if their residual lesions fall within T2 criteria.
Programming is expected for completion in 3rd quarter 2017 with implementation following in 4th quarter Educational materials will be provided to the community prior to implementation.

4. Questions?
Julie Heimbach, MD Committee Chair Matt Prentice, MPH Committee Liaison