1. Pediatric Transplantation Committee Fall 2014
Proposal to Automatically Transfer Pediatric Classification for Registered Liver Candidates Turning 18
Pediatric Transplantation Committee
Fall 2014

2. The Problem
Liver inconsistent with most other organ allocation policy for pediatrics:
Pediatric classification not automatically retained when a liver candidate turns 18
Exception: Status 1A and 1B candidates
Program can apply to RRB for pediatric classification for adult candidates (age 18 and older) to return to the waitlist if ever registered prior to age 18.
Most programs not aware of this exception process.
There are some liver policy inconsistencies when compared to other organs. Most organ candidates automatically retain pediatric priority if they turn 18 while waiting for a transplant. But under current policy, only liver candidates who are listed as Status 1A or 1B when they turn 18 will automatically retain their pediatric classification. Candidates who are waiting with a MELD score will not. Programs have to petition the RRBs for a pediatric classification exception for these candidates, and evidence suggests that most programs are not aware of this exception process.
Operationally, pediatric classification for liver candidates means prioritization as a 12 to 17 year old on a match run.
In the spring of 2013, the Pediatric Committee requested that staff publish an article on the OPTN and TransplantProSM websites explaining the pediatric classification exception process for liver candidates. We did not believe that current policy was well-understood in the community. This speculation was verified when 12 applications were submitted after the article was published, when only 3 had been requested in the previous 9 years.
Under current policy, programs can also submit pediatric classification exception applications to the RRB for adult liver candidates returning to the waiting list, if they were ever registered prior to age 18 but have since been removed. This is also inconsistent with most other organ allocation policy.

3. Goal of the Proposal
Retain pediatric classification for all liver candidates who turn 18 while waiting
Eliminate pediatric classification exception process for adults ever listed before age 18 but since removed and relisted
The Pediatric Committee proposes automatically transferring the pediatric classification for all liver candidates who turn 18 while waiting. We also seek to eliminate the pediatric classification process for adult liver candidates returning to the waiting list, if they were registered before turning 18 but have since been removed.
These proposed changes are consistent with most other organ allocation policy and promote the efficient management of the OPTN, which is a goal of the Strategic Plan. The RRBs have been consistent in their decision-making, making review of these applications unnecessary and easily automated. The proposed changes will also promote pediatric access to transplant, since more young people could have benefitted from current policy had their applications been submitted for RRB consideration.

4. Supporting Evidence RRBs consistent in decision-making
38 MELD candidates that would qualify for automatic ped classification (as of June 20)
71% (27) were years old at listing
Age 18-33, only 11% (4) older than 25
Wait time <1-17 years
Most MELD scores <13 (5 with past due re-certifications)
No previous liver transplants
Most had received at least one offer
No prevalent diagnosis
In reviewing the outcomes of pediatric classification exception applications since 2004, we learned that the RRBs have been consistent in their decision-making. All candidates that turned 18 while waiting for liver transplant were approved for pediatric classification. Although these applications are very rare, former pediatric candidates returning to the waitlist as adults were denied. This suggests that RRB review of these applications is unnecessary and easily automated.
The Committee reviewed a descriptive data analysis of 38 candidates waiting in a MELD score as of June 20, 2014, who do not currently qualify for automatic pediatric classification but would under this proposed policy. The candidates were registered at 22 different centers. Seventy-one percent of them were 15 to 17 years old at listing. Current candidate ages ranged from 18 to 33, though only 4 were currently older than 25. Time spent on the waiting list ranged from less than 1 to 17 years. Most candidates had MELD scores less than 13, although 5 candidates had re-certifications that were past due and had been assigned a MELD score of 6. None of the candidates had a previous liver transplant. Most had received at least one offer, and the most common refusal reason was donor age or quality. There was not a prevalent diagnosis among the candidates. After carefully considering the data, the Committee decided to proceed with the proposed policy; however, we stress that, as with any allocation policy, adequate and appropriate registration of patients and good waiting list management is always necessary.
The Liver and Intestinal Organ Transplantation Committee considered this proposal and unanimously voted to support it.

5. What Members will Need to Do
If approved by the Board, proposal will be implemented without any action from liver programs
Will require UNetSM programming to fully automate
If the Board approves this proposal, automatic transfer of pediatric classification will be implemented using a manual solution. No action is required of liver programs. Programming in UNetSM will eventually be required to fully automate this process. This policy will not require any changes to the Regional Review Board guidelines.
Until this policy has been approved by the Board, a program that wishes for its liver candidate to retain pediatric classification upon turning 18 must submit an exception application to the RRB.

6. Questions? Eileen Brewer, MD Committee Chair ebrewer@bcm.edu
Regional representative name (RA will complete) Region X Representative address
Christine Flavin, MPH Committee Liaison