PELD: working well, but only half of the time?

The implementation of MELD and PELD represented an enormous advance toward allocation of deceased donor livers according to objective criteria that reflect illness severity. PELD, developed using the Studies of Pediatric Liver Transplantation database, formed the basis of liver allocation for children (<18 years) (1). To acknowledge that a mathematical model cannot adequately reflect every individual’s need for transplant, the allocation policy retained Status 1 designation for both acute and chronic liver disease and established a mechanism to assign increased priority above the objectively calculated score. This process entails peer review by a regional review board (RRB). The RRB decides, based upon the request of the transplant physician, the merits of the case and the local dynamics of transplant access, whether to grant Status 1 designation or to assign an increased PELD score. Explicit in the development of these new policies was the need for frequent assessment with regard to efficacy and equity.