Key provisions of the liver allocation policy ensure that:

• Those patients who are acutely ill and in danger of death within hours or days will be listed as Status 1 patients.
• Standardized liver waiting list criteria and regional review boards will be used when placing patients with chronic liver disease on the waiting list for liver transplants. This will provide equitable and consistent access to the waiting list for all patients around the country.

Current Transplant Candidacy Status.

• Status 1:
  A patient greater than or equal to 18 years of age with fulminant (acute) liver failure with a life expectancy without liver transplant of less than 7 days. This includes:
   
  
  • Fulminant hepatic failure defined as the onset of hepatic encephalopathy within 8 weeks of the first symptoms of liver disease. The absence of pre-existing liver disease is critical to this diagnosis. While no single clinical observation or laboratory test defines fulminant hepatic failure, the diagnosis is based on the finding of stage II encephalopathy (i.e., drowsiness, inappropriate behavior, and asterixis) in a patient with severe liver dysfunction. Evidence of severe liver dysfunction may be manifest by some or all of the following symptoms and signs: asterixis (flapping tremor), elevated bilirubin (i.e., >15 mg/dL), marked prolongation of the prothrombin time clotting factors (i.e., >20 sec or INR >2.5), or low blood sugars; or.
     
    
  • Primary non-function of a transplanted liver within 7 days of implantation; or
     
    
  • Hepatic artery thrombosis in a transplanted liver within 7 days of implantation; or
     
    
  • Acute decompensated Wilson's disease;
     
    
• Status 2A:
  A patient listed as Status 2A is in the hospital's critical care unit due to chronic liver failure with a life expectancy without a liver transplant of less than 7 days, and has a long-term prognosis with a successful liver transplant equivalent to that of a patient with fulminant liver failure. The patient also has a Child's-Turcotte-Pugh (CTP) score greater than or equal to 10 and meets at least one of the following medical criteria:
   
  
  • Documented unresponsive active variceal hemorrhage:   Endoscopically confirmed variceal hemorrhage requiring at least two units of red blood cell replacement, which continues or recurs after a series of endoscopic sclerotherapy/banding treatments to ablate the varices, or endoscopically confirmed portal hypertensive gastropathy requiring at least two units of red blood cell replacement, which continues or recurs. For either variceal or gastropathy hemorrhage, transjugular intrahepatic portosystemic shunt placement (TIPS), or other surgical shunt, must be either contraindicated or failed to control the bleeding.
     
    
  • Hepatorenal Syndrome:   The presence of progressive deterioration of renal function in a patient with advanced liver disease requiring hospitalization for management, with no other known etiology of renal insufficiency, and a rising serum creatinine of 1.5 mg/dL (adult) or 3 times baseline in a child less than 15 years of age. In addition to these major criteria, the patient should meet at least one of the following: 1) urine volume <500 mL/day (adult), or <10- mL/kg/day in patients less than 15 years of age; b) urine sodium <10 mEq/mL; or c) urine osmolality > plasma osmolality (U/P ratio >1.0).
     
    
  • Refractory Ascites/Hepatic Hydrothorax:   Severe persistent ascites or hepatic hydrothorax unresponsive to diuretic and salt restriction therapy and requiring either large volume paracentesis of at least 4 liters, or for respiratory distress, more frequently than every 2 weeks with a contraindication or failure of a TIPS procedure to control ascites.
     
    
  • Encephalopathy:    Stage III or IV encephalopathy unresponsive to medical therapy.
     
    
  A patient shall NOT be listed as a Status 2A if the patient meets at least one of the following medical criteria:
   
  
  • extrahepatic sepsis unresponsive to antimicrobial therapy;
     
    
  • requirement for high-dose, or 2 or more pressors to maintain adequate blood pressure;
     
    
  • severe irreversible multi-organ system failure.
  
   
  
• Status 2B:
  Has a CTP score greater than or equal to 10, or a CTP score greater than or equal to 7 and meets at least 1 of the following medical criteria:
   
  
  • Documented unresponsive active variceal hemorrhage:   Endoscopically confirmed variceal hemorrhage requiring at least two units of red blood cell replacement, which continues or recurs after a series of endoscopic sclerotherapy/banding treatments to ablate the varices, or endoscopically confirmed portal hypertensive gastropathy requiring at least two units of red blood cell replacement, which continues or recurs. For either variceal or gastropathy hemorrhage, TIPS, or other surgical shunt, must be either contraindicated or failed to control the bleeding.
     
    
  • Hepatorenal Syndrome:   The presence of progressive deterioration of renal function in a patient with advanced liver disease requiring hospitalization for management, with no other known etiology of renal insufficiency, and a rising serum creatinine of 1.5 mg/dL (adult) or 3 times baseline in a child less than 15 years of age. In addition to these major criteria, the patient should meet at least one of the following: 1) urine volume <500 mL/day (adult), or <10- mL/kg/day in patients less than 15 years of age; b) urine sodium <10 mEq/mL; or c) urine osmolality > plasma osmolality (U/P ratio >1.0).
     
    
  • Spontaneous Bacterial Peritonitis:   The occurrence of a single episode of spontaneous bacterial peritonitis documented by at least one of the following:  a) a positive culture of ascitic fluid for bacteria; b) a gram stain of ascitic fluid positive for the presence of bacteria; or c) an ascitic fluid white blood cell count with greater than 300 polymorphonuclear cells per milliliter, or a total of 500 white blood cells per milliliter.
     
    
  • Refractory Ascites/Hepatic Hydrothorax:   Severe persistent ascites or hepatic hydrothorax unresponsive to diuretic and salt restriction therapy and requiring either large volume paracenteses of at least 4 liters, or for respiratory distress, more frequently than every 2 weeks with a contraindication or failure of a TIPS procedure to control ascites.
     
    
• Status 3
  Requires continuous medical care and has a CTP score greater than or equal to 7. Status 3 patients may be followed at home or near the transplant center. Short hospitalizations for intercurrent problems are not considered justifications for a change in status.
   
  
• Status 7
  Temporarily inactive, however, the patient continues accruing waiting time up to a maximum of 30 days. Patients who are considered to be temporarily unsuitable transplant patients (i.e., infected, medically noncompliant) will be listed as status 7, temporarily inactive.
   
  

The United Network for Organ Sharing (UNOS) and transplant centers around the country are always evaluating this system. We constantly determine whether the system meets the need of the liver transplant patient and upgrades are done frequently to maximize the scarce resource of organs and recipient survival.