New national liver transplant allocation policy: is the regional review board process fair?

Experienced transplant professionals may predict mortality better, in highly selected cirrhotic patients referred for accelerated listing to regional review boards, than the (Pediatric) Model for End-Stage Liver Disease score. However, these requests are often denied. We wished to establish if (1) such denials increase mortality and (2) referring physicians predict mortality better than the score. We analyzed 1,965 non-status 1 requests made between February and November 2002 from the United Network for Organ Sharing (UNOS) national scientific registry. Kaplan-Meier survival and time to transplant were compared between denied and approved patients. Cox proportional hazards analysis was used to establish if referring physicians predicted mortality better than the score. More requests were denied for patients with nonsanctioned conditions (45.7%) than for those with sanctioned conditions (13.3%); P less than.0001). Fewer patients denied accelerated listing had a transplant (46.6% vs. 63.8%; P <.0001); time to transplant was similar (P =.2). However, nonsanctioned cirrhotic cases denied accelerated listing had lower mortality than approved cases (P <.04). Referring physicians predict mortality poorly (P =.23), whereas the Model for End-Stage Liver Disease (MELD)-Pediatric Model for End-Stage Liver Disease (PELD) score was highly predictive (P =.0003). In conclusion, regional review boards are fair and can accurately distinguish high- from low-risk patients. Denying requests does not increase mortality. The MELD-PELD score remains the best predictor of mortality, but the review board process adds additional information. Referring physicians predict patient mortality poorly.