Standardizing MELD Exceptions: Current Challenges and Future Directions

Since Model for End-Stage Liver Disease (MELD)-based allocation was implemented in 2002, 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. These exceptions, categorized as standardized and non-standardized, have been used with increasing frequency over time. Several challenges to the exception point system have emerged, including lack of standardization in the criteria used to approve such exceptions, geographic variability in the use and approval of such exceptions, and a limited evidence base to support certain exceptions. Herein, we summarize the current implementation of exception points, the challenges facing the transplant community, and suggestions for improving and standardizing the current exception point system.