MELD Exceptions in PSC Under Scrutiny : Liver Transpl | June 2026

Introduction:

Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease that frequently progresses to liver failure, recurrent bacterial cholangitis, and the need for liver transplantation. Because the Model for End-Stage Liver Disease (MELD) score may not fully capture the disease burden experienced by some patients with PSC, exception policies have been developed to provide additional transplant priority in selected circumstances. However, the appropriateness and effectiveness of these exceptions remain an area of ongoing debate.

Problem Statement:

MELD exception policies are intended to address clinical situations in which standard MELD scores underestimate transplant urgency. In PSC, exceptions have often been granted for recurrent cholangitis and other disease-related complications, yet the supporting evidence has been limited and inconsistent. Determining whether these policies accurately identify patients with increased mortality risk or improved transplant benefit is essential to maintaining fairness in organ allocation.

Summary:

This editorial examines the current practice of granting MELD exception points for patients with PSC and questions whether existing policies are sufficiently supported by robust clinical evidence. The authors highlight a central challenge in transplant allocation: balancing the need to recognize PSC-specific complications while ensuring equitable organ distribution across all liver disease populations. Although recurrent bacterial cholangitis and related complications can significantly impair quality of life and contribute to morbidity, evidence linking these events to a clearly increased waitlist mortality risk remains limited. The editorial argues that exception policies should be driven by objective data demonstrating measurable transplant benefit rather than historical practice patterns or expert consensus alone. The authors emphasize the need for contemporary outcome-based studies that evaluate waitlist mortality, post-transplant outcomes, and the true impact of PSC-related complications on patient prognosis. As transplant medicine increasingly moves toward evidence-based allocation systems, reassessment of PSC exception policies may be necessary to ensure fairness, transparency, and optimal use of scarce donor organs. The article ultimately calls for stronger data to guide future policy decisions and to determine whether current MELD exception practices for PSC remain justified in modern liver transplantation.