Abstract
In the United States, since 2019, liver transplant waitlist candidates who are approved for a MELD exception are awarded points that vary based on geography. The number of points is based on the median MELD score at transplant minus 3 (MMAT-3) of recipients within a specific area, which has changed over time. However, the MMAT is calculated based only on recipients ≥12 years of age transplanted with a liver from a donation after brain death donor located within 500 nautical miles of the transplant hospital. When the policy was first implemented, the restriction to only these donors had little impact as they comprised the majority of deceased liver donors. However, with broader use of donation after circulatory death donors, who represent nearly 40% of all deceased liver donors in the US, the calculation of MMAT based only on donation after brain death donors has led to a marked difference in the calculated MMAT used for awarding exception points and the actual MMAT. In this viewpoint, we highlight the changes in exception policy, the growing difference between the policy-based MMAT and the actual MMAT and propose policy changes to ensure allocation rules reflect current practice.