Exception points for liver transplantation: A Canadian review

Stephen E Congly; Vladimir Marquez; Rahima A Bhanji; Mamatha Bhat; Philip Wong; Geneviève Huard; Julie H Zhu; Mayur Brahmania

doi:10.3138/canlivj-2022-0026

Exception points for liver transplantation: A Canadian review

Can Liver J. 2023 Jul 26;6(2):201-214. doi: 10.3138/canlivj-2022-0026. eCollection 2023 Jul.

Authors

Stephen E Congly^{1

2}, Vladimir Marquez³, Rahima A Bhanji⁴, Mamatha Bhat⁵, Philip Wong⁶, Geneviève Huard⁷, Julie H Zhu⁸, Mayur Brahmania⁹

Affiliations

¹ Divisions of Gastroenterology and Hepatology and Transplant Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
² O'Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada.
³ Division of Gastroenterology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.
⁴ Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada.
⁵ Ajmera Transplant Program, University Health Network and Division of Gastroenterology & Hepatology, University of Toronto, Toronto, Ontario, Canada.
⁶ Division of Gastroenterology and Hepatology, McGill University Health Centre, Royal Victoria Hospital, Montréal, Quebec, Canada.
⁷ Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada.
⁸ Division of Digestive Care & Endoscopy, Dalhousie University and Atlantic Multi-Organ Transplantation Program, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada.
⁹ Division of Gastroenterology, Department of Medicine, and Multi Organ Transplant Unit, London Health Sciences Centre, Western University, London, Ontario, Canada.

Abstract

Background: Exception points 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 exception points 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 exception points based on the median MELD-Na score with modifications; Alberta, Ontario, and Quebec grant exception points using specific values based on the indication. Overall, there was significant heterogeneity regarding exception points granted nationally with agreement only for awarding exception points for hepatopulmonary syndrome and polycystic liver disease. The second most common agreed-upon indications for exception points 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.

Keywords: allocation; eMELD; ePELD; health policy.