Exception points for liver transplantation: A Canadian review

Abstract

Background: Exception points (EP) for liver transplant (LT) allocation are used to account for mortality risk not reflected by scoring systems such as the Model for End-Stage Liver Disease with sodium (MELD Na). Currently, there is no formal policy regarding EP in Canada and differences across the country are not well understood. As such, a review of the criteria and exception points granted throughout the country for LT was conducted. Methods: Seven LT centres in five provinces were surveyed (Vancouver, Edmonton, London, Toronto, Montréal, Halifax) regarding the indications and criteria for exception points granted, the number of points granted, how points would be accrued, and the maximum points granted. Results: Programs in British Columbia and Nova Scotia grant variable EP based on the median MELD Na score with modifications; Alberta, Ontario, and Quebec grant EP using specific values based on the indication. Overall, there was significant heterogeneity regarding EP granted nationally with agreement only for awarding EP for hepatopulmonary syndrome and polycystic liver disease. The second most common agreed-upon indications for EP were portopulmonary hypertension and recurrent cholangitis offered by four provinces. Quebec had the most formal criteria for non-cirrhosis-based conditions. Conclusions: There is substantial variance across the country regarding the indications for granting exception points as well as the number of points granted. Future work on developing a national consensus will be important for the development of equity in LT across Canada.