1. Proposal to Cap the HCC Exception Score at 34
Liver and Intestinal Organ Transplantation Committee
Spring 2014

2. The Problem Share 35 policy implemented 6/18/2013
Goal: Direct livers to those most at risk of death
BUT: Livers are being offered regionally to candidates with a very low risk of waiting list death / dropout
Candidates with HCC Exception scores >=35
Contrary to the intent of Share 35
Share 35 was implemented in June 2013, with the goal of directing livers to those at greatest risk of waiting list death.
One unintended consequence of the Share 35 policy is that livers are being offered regionally to a subset of candidates with a very low risk of waiting list death or dropout, those with HCC exceptions.
In recent years, candidates with HCC exceptions have begun to accrue scores of 35 and higher, and due to Share 35 are now competing with very sick candidates for the regional donor pool.
This runs contrary to the goals of Share 35.

3. Goal of the Proposal
Maintain regional priority for those most in need by capping the HCC exception score at 34
This proposal would cap the HCC exception score at 34, in effect giving candidates with calculated MELD/PELD scores of 35 and higher a better opportunity to receive regional offers under the new policy.

4. Supporting Evidence
MELD/PELD Score 35+ candidate have high mortality risk, similar to Status 1 (Sharma, et al)
HCC exception candidates have low waiting list death/dropout (Washburn, et al, Massie, et al)
Number of HCC exception scores 35+ increasing
Only 6 in cases in 2013
Many as “Other, specify” with HCC criteria entered into narrative
Candidates with score of 35 and higher have a mortality risk similar to that of Status 1 candidates . We’ve had regional sharing for Status 1 candidates for since 2010.
On the other hand, candidates with a HCC exceptions have a much lower risk of disease progression or dropout (such as removal from the waiting list for death or being too sick) than candidates with calculated MELD/PELD scores of 35 and higher. This has been shown in several studies.
When Share 35 was being developed in 2009 and 2010, there were very few candidates with HCC exceptions scores that reached 35. This number has been steadily increasing. There were 41 cases in 2013 compared with only 6 in 2010.
Unfortunately, many of these are submitted as “Other specify” which will complicate matters. I’ll discuss this later in the presentation.

5. Additional Background
Candidates with HCC exceptions receive increases every 3 months
Most patients treated (90%), many with stable tumors
Capped candidates will still receive priority for local offers
May petition the RRB if need for higher priority is demonstrated
It is important to remember that most candidates with HCC receive loco-regional treatment. Many have stable tumors and may not require a transplant any time soon. However, these candidates receive automatic score increases every 3 months as long as they continue to meet policy criteria.
These candidates would still receive priority for local offers, and centers may petition the Regional Review Board (RRB) for a candidate that demonstrates the need for higher priority.

6. What Members will Need to Do
HCC exception scores will be capped at 34
Centers can still petition RRB
Those cases submitted as “Other, specify” will be monitored by the Liver Committee
This policy change would require programming in UNet, and would happen automatically once a candidate reaches a score of 34. Again, there is always the option to put a case before the RRB.
Those submitted as “other specify” cannot be capped in UNet as they are automatically sent to the RRB, but these cases will be monitored by the Liver Committee.

7. Questions? David C. Mulligan, MD Committee Chair
Name Region # Representative
Ann Harper Committee Liaison