Guest guest Posted August 17, 1999 Report Share Posted August 17, 1999 The search engine on the UNOS site is acting up but I found it by going to About Unos then Policies then Liver Allocation. To save everyone some work, here is the text (sorry for the long message): June 25, 1999 Return to Policies Table of Contents Policy 3.6 Organ Distribution 3.6 Allocation of Livers. Unless otherwise approved according to Policies 3.1.7 (Local and Alternative Local Unit), 3.1.8 (Sharing Arrangement and Sharing Agreement), 3.1.9 (Alternate Point Assignments (Variances)), and Policy 3.4.6 (Application, Review, Dissolution and Modification Processes for Alternative Organ Distribution or Allocation Systems), the allocation of livers according to the following point system is mandatory first locally, then regionally, and then nationally. Each patient will be assigned a status code corresponding to the degree of medical urgency as described in Policy 3.6.4 below. Each patient also will be assigned points for conditions as described in Policies 3.3.5, 3.6.2, 3.6.3, and 3.6.4. Livers will be offered for patients with an assigned Status of 1 in descending point sequence with the patient having the highest number of points receiving the highest priority before being offered for patients listed in other status categories. Following Status 1, livers will be offered for patients with an assigned Status of 2A in descending point sequence with the patient having the highest number of points receiving the highest priority before being offered for patients listed in less urgent statuses. Following Status 2A, livers will be offered for patients with an assigned status of 2B in descending point sequence with the patient having the highest number of points receiving the highest priority. Following Status 2B, livers will be offered for patients with an assigned status of 3 in descending point sequence with the patient having the highest number of points receiving the highest priority. Livers will not be offered to patients with a status of 7. Livers will be allocated in the following sequence: Local 1. Status 1 patients in descending point order 2. Status 2A patients in descending point order 3. Status 2B patients in descending point order 4. Status 3 patients in descending point order Regional 1. Status 1 patients in descending point order 2. Status 2A patients in descending point order 3. Status 2B patients in descending point order 4. Status 3 patients in descending point order National 1. Status 1 patients in descending point order 2. Status 2A patients in descending point order 3. Status 2B patients in descending point order 4. Status 3 patients in descending point order The liver must be transplanted into the original designee or be released back to the donor center or to the UNOS Organ Center for distribution. The final decision whether to use the organ will remain the prerogative of the transplant surgeon and/or physician responsible for the care of that patient. This will allow physicians and surgeons to exercise judgment about the suitability of the organ being offered for their specific patient; to be faithful to their personal and programmatic philosophy about such controversial matters as the importance of cold ischemia and anatomic anomalies; and to give their best assessment of the prospective recipient's medical condition at the moment. If an organ is declined for a patient, a notation of the reason for the decision not to accept the liver for that patient must be made on the appropriate UNOS form and promptly submitted to UNOS. 3.6.1 Preliminary Stratification. For every potential liver recipient, the acceptable donor size must be determined by the responsible surgeon. The UNOS Match System will consider only potential liver recipients who are an acceptable size for that particular donor liver. 3.6.2 Blood Type Similarity Points. Except as specified in Policy 3.6.2.1 and 3.6.2.2, transplant candidates with the same ABO type as the liver donor shall receive 10 points. Candidates with compatible but not identical ABO types shall receive 5 points, and candidates with incompatible types shall receive 0 points. Blood type O candidates who will accept a liver from an A2 blood type donor shall receive 5 points for ABO incompatible matching. 3.6.2.1 Blood Type O Liver Allocation. Blood type O livers shall not be transplanted into Status 2B or 3 candidates who are not a blood type O. 3.6.2.2 Liver Allocation to Candidates Registered Under Blood Type " Z " . The blood type " Z " designation may be added as a suffix to a candidate's actual blood type, (e.g., " AZ " ) only for Status 1 candidates, or Status 2A candidates, who will accept a liver from a donor of any blood type. Liver candidates registered under blood type Z shall receive 0 points for ABO incompatible matching. 3.6.3 Time Waiting.The " time of waiting " begins when a patient is initially placed on the UNOS Patient Waiting List. Ten points will be accrued by the patient waiting for the longest period for a liver transplant and proportionately fewer points will be accrued by those patients with shorter tenure. For example, if there were 75 persons of O blood type waiting who were of a size compatible with a blood group O donor, the person waiting the longest would accrue 10 points (75/75 x 10). A person whose rank order was 60 would accrue 2 points. (75-60/75 x 10 = 2) 3.6.3.1 Status 1 and 2A Liver Patients. Time of waiting will be calculated for Status 1 and Status 2A liver patients from the time the patient is listed as a Status 1 or 2A and will only include time listed as a Status 1 or 2A. 3.6.3.2 Waiting Time for Liver Transplant Candidates in an Inactive Status. Patients shall be allowed to accrue an aggregate of 30 days inactive status waiting time. A patient's waiting time accrued during each occurrence of inactivation shall be calculated on a cumulative basis so that once the 30 day aggregate limit is reached no additional waiting time shall accrue on further occurrences of inactivation. 3.6.4 Degree of Medical Urgency. Each patient is assigned a status code which corresponds to how medically urgent it is that the patient receive a transplant. 3.6.4.1 Adult Patient Status. Medical urgency is assigned to an adult liver transplant patient (greater than or equal to 18 years of age) based on the criteria set forth in Table 1 and defined as follows. A patient who does not meet the criteria for a particular status may nevertheless be assigned to such status upon application by his/her transplant physician(s) and justification to the applicable Regional Review Board that the patient is considered, using accepted medical criteria, to have an urgency and potential for benefit comparable to that of other patients in this status as defined below. The justification must include a rationale for incorporating the exceptional case as part of the criteria. A report of the decision of the Regional Review Board and the basis for it shall be forwarded to UNOS for review by the Liver and Intestinal Organ Transplantation and Membership and Professional Standards Committees to determine consistency in application among and within Regions and continued appropriateness of the patient status criteria. Status Definition 7 A patient listed as Status 7 is temporarily inactive; however, the patient continues accruing waiting time up to a maximum of 30 days. UNOS staff will confirm the inactive status at the end of 30 days. Patients who are considered to be temporarily unsuitable transplant patients are listed as Status 7, temporarily inactive. 3 A patient listed as Status 3 requires continuous medical care and has a Child-Turcotte-Pugh (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. 2B A patient listed as 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: (i) 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. (ii) 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. In addition to these major criteria, the patient should meet at least one of the following: a.) urine volume < 500 ml/d; b.) urine sodium <10 mEq/ml; or c.) urine osmolality > plasma osmolality (U/P ratio >1.0). (iii) 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. (iv) Refractory Ascites/Hepato-Hydrothorax; Severe persistent ascites or hepato-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. A completed Liver Status 2B Justification Form must be received by UNOS within one working day of a patient's listing as a Status 2B. If a completed Liver Status 2B Justification Form is not received by UNOS within one working day of a patient's listing as a Status 2B, the patient shall be re-assigned to a Status 3. The appropriateness of each Status 2B patient listing shall be re-assessed by the listing transplant center at 6 months from the date the patient is initially listed as a Status 2B and every 6 months thereafter. This reassessment must be based on clinical information (e.g., laboratory test results and diagnosis) that is obtained within the prior 30 days. A completed Liver Status 2B Justification Form must be received by UNOS 6 months from the date the patient is initially listed as a Status 2B and every 6 months thereafter for the duration of the patient's listing as a Status 2B. UNOS shall notify the listing transplant center of the need to reassess a Status 2B patient 30 days prior to the 6-month deadline. If a completed Liver Status 2B Justification Form is not received by UNOS 6 months from the date the patient is initially listed as a Status 2B and every 6 months thereafter, the patient shall be re-assigned to a Status 3. Status Definition 2A Status 2A provides a transition for currently listed adult patients with chronic liver disease who may have qualified for Status 1, as this category was defined prior to July 4, 1997, and an opportunity to assess the usefulness of such a category when monitored by UNOS Regional Review Boards. An upgrade to Status 2A shall be reviewed by the applicable UNOS Regional Review Board and is intended for the exceptional patient with chronic liver disease who meets the criteria for Status 2B and whose clinical condition acutely deteriorates as defined by the following criteria. 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 CTP score greater than or equal to 10 and meets at least one of the following medical criteria: (i) 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. (ii) 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. In addition to these major criteria, the patient should meet at least one of the following: a.) urine volume < 500 ml/d; b.) urine sodium <10 mEq/ml; or c.) urine osmolality > plasma osmolality (U/P ratio >1.0). (iii) Refractory Ascites/Hepato-Hydrothorax; Severe persistent ascites or hepato-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. (iv) Stage III or IV encephalopathy unresponsive to medical therapy; A patient shall not be listed as Status 2A if the patient meets at least one of the following medical criteria: (i) Extrahepatic sepsis unresponsive to antimicrobial therapy; (ii) Requirement for high-dose, or 2 or more pressors to maintain adequate blood pressure; (iii) Severe irreversible multi-organ system failure. Patients who are listed as a Status 2A automatically revert back to Status 2B after 7 days unless these patients are relisted as Status 2A by an attending physician. A completed Liver Status 2A Justification Form must be received by UNOS within 24 hours of a patient's original listing as a Status 2A and each relisting as a Status 2A. If a completed Liver Status 2A Justification Form is not received by UNOS within 24 hours of the Status 2A liver candidate registration on the waiting list, the candidate shall be reassigned to a Status 2B. A relisting request to continue a Status 2A listing for the same patient waiting on that specific transplant beyond 14 days accumulated time will result in an on-site review of all local Status 2 liver patient listings. 1 A patient greater than or equal to 18 years of age listed as Status 1 has fulminant liver failure with a life expectancy without a liver transplant of less than 7 days. For the purpose of Policy 3.6, fulminant liver failure shall be defined as: (i) 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 the 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, incontinence with 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), hyperbilirubinemia (i.e., bilirubin>15mg%), marked prolongation of the prothrombin time (i.e., >20sec or INR>2.5), or hypoglycemia.; or (ii) primary non-function of a transplanted liver within 7 days of implantation; or (iii) hepatic artery thrombosis in a transplanted liver within 7 days of implantation; or (iv) acute decompensated 's disease. Patients who are listed as a Status 1 automatically revert back to Status 2B after 7 days unless these patients are relisted as Status 1 by an attending physician. A patient listed as Status 1 shall be reviewed by the applicable UNOS Regional Review Board. A completed Liver Status 1 Justification Form must be received by UNOS within 24 hours of a patient's original listing as a Status 1 and each relisting as a Status 1. If a completed Liver Status 1 Justification Form is not received by UNOS within 24 hours of the Status 1 liver candidate registration on the waiting list, the candidate shall be reassigned to a Status 2B. A relisting request to continue a Status 1 listing for the same patient waiting on that specific transplant beyond 14 days accumulated time will result in an on-site review of all local Status 2 and 1 liver patient listings. Table 1 Child-Turcotte-Pugh (CTP) Scoring System to Assess Severity of Liver Disease Points 1 2 3 Encephalopathy None 1 - 2 3 - 4 Ascites Absent Slight (or controlled by diuretics) At least moderate despite diuretic treatment Bilirubin (mg/dl) <2 2-3 >3 Albumin (g/dl) >3.5 2.8-3.5 <2.8 Prothrombin time (secs. prolonged) <4 4-6 >6 or (INR) <1.7 1.7-2.3 >2.3 For primary biliary cirrhosis, primary sclerosing cholangitis, or other cholestatic liver diseases: Bilirubin (mg/dl)* <4 4-10 >10 * For cholestatic liver diseases, these values for bilirubin are to be substituted for the values above. ---------------------------------------------------------------------------- ---- 3.6.4.2 Pediatric Patient Status. Medical urgency is assigned to a pediatric liver transplant patient (less than 18 years of age) based on the criteria defined as follows, including criteria set forth in Appendix 3B. A patient who does not meet the criteria for a particular status may nevertheless be assigned to such status upon application by his/her transplant physician(s) and justification to the applicable Regional Review Board that the patient is considered, using accepted medical criteria, to have an urgency and potential for benefit comparable to that of other patients in this status as defined below. The justification must include a rationale for incorporating the exceptional case as part of the criteria. A report of the decision of the Regional Review Board and the basis for it shall be forwarded to UNOS for review by the Liver and Intestinal Organ Transplantation and Membership and Professional Standards Committees to determine consistency in application among and within Regions and continued appropriateness of the patient status criteria. Status Definition 7 A pediatric patient listed as Status 7 is temporarily inactive; however, the patient continues accruing waiting time up to a maximum of 30 days. UNOS staff will confirm the inactive status at the end of 30 days. Patients who are considered to be temporarily unsuitable transplant patients are listed as Status 7, temporarily inactive. 3 A pediatric patient listed as Status 3 has met the inclusion criteria to be listed for pediatric liver transplantation as set forth in Appendix 3B, and requires continuous medical care. Status 3 patients may be followed at home or near the transplant center. Short hospitalization for intercurrent problems are not considered justification for a change in status. 2B A pediatric patient listed as Status 2B meets at least one of the following medical criteria: (i) Documented, unresponsive upper gastro-intestinal bleeding requiring transfusion of at least 10 cc/kg of red blood cells. (ii) 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 3 times baseline. In addition to these major criteria, the patient should meet at least one of the following: a) urine volume < 10 ml/kg/d; urine sodium < 10 mEq/l; or c) urine osmolality > plasma osmolality (U/P ratio > 1.0). (iii) 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; 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. (iv) Refractory Ascites/Hepato-Hydrothorax: Severe persistent ascites or hepatohydrothorax, defined as any one of the following: unresponsive to diuretic and salt restriction therapy leading to respiratory distress, or requiring supplemental tube feeding, or requiring parenteral nutrition, or requiring paracenteses. (v) Recurrent cholangitis defined as 2 or more episodes in 6 months requiring hospitalization and intravenous antibiotics. (vi) Growth failure i.e. < 5th percentile for weight and/or height, or loss of 1.5 standard deviations score of expected growth (height or weight) based on the National Institute of Health Statistics for pediatric growth curves and requiring initiation of parenteral nutritional support, or nasogastric feedings to supply a minimum of 30% of caloric needs. (vii) A patient who meets at least 3 of the 5 following criteria: (1) ascites requiring diuretic therapy (2) bilirubin > 4 mg/dl (3) albumin < 3 g/dl (4) INR > 1.7 (5) malnutrition defined as loss of 1 standard deviation score of expected growth. A completed Liver Status 2B Justification Form must be received by UNOS within one working day of a pediatric patient's listing as a Status 2B. If a completed Liver Status 2B Justification Form is not received by UNOS within one working day of a patient's listing as a Status 2B, the patient shall be re-assigned to a Status 3. The appropriateness of each Status 2B patient listing shall be re-assessed by the listing transplant center at 6 months from the date the patient is initially listed as a Status 2B and every 6 months thereafter. This reassessment must be based on clinical information (e.g., laboratory test results and diagnosis) that is obtained within the prior 30 days. A completed Liver Status 2B Justification Form must be received by UNOS 6 months from the date the patient is initially listed as a Status 2B and every 6 months thereafter for the duration of the patient's listing as a Status 2B. UNOS shall notify the listing transplant center of the need to reassess a Status 2B patient 30 days prior to the 6-month deadline. If a completed Liver Status 2B Justification Form is not received by UNOS 6 months from the date the patient is initially listed as a Status 2B and every 6 months thereafter, the patient shall be re-assigned to a Status 3. 1 A pediatric patient listed as Status 1 is located in the hospital's Intensive Care Unit (ICU) due to acute or chronic liver failure, has a life expectancy without a liver transplant of less than 7 days and meets at least 1 of the following criteria: (i) 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 the 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, incontinence with 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), hyperbilirubinemia (i.e., bilirubin>15mg%), marked prolongation of the prothrombin time (i.e., >20sec or INR>2.5), or hypoglycemia. (ii) Primary non-function of a transplanted liver within 7 days of implantation. (iii) Hepatic artery thrombosis in a transplanted liver within 7 days of implantation. (iv) Acute decompensated 's disease. (v) On mechanical ventilator. (vi) Upper gastro-intestinal bleeding requiring at least 10 cc/kg of red blood cell replacement which continues or recurs despite treatment. (vii) 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 3 times baseline. In addition to these major criteria, the patient should meet at least one of the following: a) urine volume < 10 ml/kg/d; urine sodium < 10 mEq/l; or c) urine osmolality > plasma osmolality (U/P ratio > 1.0). (viii) Stage III or IV encephalopathy unresponsive to medical therapy. (ix) Refractory Ascites/Hepato-Hydrothorax: Severe persistent ascites or hepatohydrothorax, defined as any one of the following: unresponsive to diuretic and salt restriction therapy leading to respiratory distress, or requiring supplemental tube feeding, or requiring parenteral nutrition, or requiring supplemental oxygen, or requiring paracentesis. (x) Biliary sepsis requiring pressor support of 5 mcg/kg/min of dopamine or greater. With the exception of hospitalized pediatric liver transplant candidates with Ornithinine Transcarbamylase Deficiency (OTC) or Crigler-Najjar Disease Type I, patients who are listed as a Status 1 automatically revert back to Status 2B after 7 days unless these patients are relisted as Status 1 by an attending physician. A patient listed as Status 1 shall be reviewed by the applicable UNOS Regional Review Board. A completed Liver Status 1 Justification Form must be received by UNOS within 24 hours of a patient's original listing as a Status 1 and each relisting as a Status 1. If a completed Liver Status 1 Justification Form is not received by UNOS within 24 hours of the Status 1 liver candidate registration on the waiting list, the candidate shall be reassigned to a Status 2B. A relisting request to continue a Status 1 listing for the same patient waiting on that specific transplant beyond 14 days accumulated time will result in an on-site review of all local Status 2 and 1 liver patient listings. 3.6.4.3 Pediatric Liver Transplant Candidates with OTC or Crigler-Najjar Disease Type I. A pediatric liver transplant candidate with Ornithine Transcarbamylase Deficiency (OTC) or Crigler-Najjar Disease Type I shall be registered as a Status 2B and may be upgraded to a Status 1 if the patient is hospitalized for an acute exacerbation of their disease. The patient shall remain a Status 1 as long as he or she remains hospitalized. 3.6.4.4 Liver Transplant Candidates with Hepatocellular Carcinoma (HCC). A patient with HCC may be registered as a Status 2B if the patient meets all of the following medical criteria: (i) The patient has known HCC and has undergone a thorough assessment to evaluate the number and size of tumors and to rule out any extrahepatic spread and/or macrovascular involvement (i.e., portal or hepatic veins). A pre-listing biopsy is not mandatory but the lesion must meet established imaging criteria. Histological grade, the presence of encapsulation or histological classification (fibrolamellar versus non-fibrolamellar) are not considered in determining the patient's listing as a Status 2B since a pre-listing biopsy is not required. The assessment of the patient should include ultrasound of the patient's liver, a computerized tomography (CT) or magnetic resonance imaging (MRI) scan of the abdomen and chest, and a bone scan. A re-assessment of the patient must be performed at every 3 month interval that the patient is on the UNOS waiting list. (ii) The patient has Stage I or Stage II HCC in accordance with the modified Tumor-Node-Metastasis (TNM) classification set forth in the following Table 2, or the patient has an alpha fetoprotein level that is rising on 3 consecutive occasions with an absolute value >/= 500 nanograms even though there is no evidence of a tumor based on imaging studies. (iii) The patient is not a resection candidate. A patient with HCC at Stage III or higher may continue to be considered a liver transplant candidate in accordance with each center's own specific policy or philosophy, but the patient must be listed as a Status 3, unless the candidate meets the other criteria specified for Status 2B or 2A in Policy 3.6.4. In addition, a patient with HCC must be reviewed by the applicable UNOS liver regional review board prior to being upgraded to a Status 2B. Table 2 American Liver Tumor Study Group Modified Tumor-Node-Metastasis (TNM) Staging Classification (1) Classification Definition TX, NX, MX Not assessed TO, NO, MO Not found T1 1 nodule <1.9 cm T2 One nodule 2.0-5.0 cm; two or three nodules, all <3.0 cm T3 One nodule >5.0 cm; two or three nodules, at least one >3.0 cm T4a Four or more nodules, any size T4b T2, T3, or T4a plus gross intrahepatic portal or hepatic vein involvement as indicated by CT, MRI, or ultrasound N1 Regional (portal hepatis) nodes, involved M1 Metastatic disease, including extrahepatic portal or hepatic vein involvement Stage 1 T1 Stage II T2 Stage III T3 Stage IV A1 T4a Stage IV A2 T4b Stage IV B Any N1, any M1 Reference: 1. American Liver Tumor Study Group - A Randomized Prospective Multi-Institutional Trial of Orthotopic Liver Transplantation or Partial Hepatic Resection with or without Adjuvant Chemotherapy for Hepatocellular Carcinoma. Investigators Booklet and Protocol. 1998. 3.6.4.4.1 Pediatric Liver Transplant Candidates with Hepatoblastoma. A pediatric patient with non-metastatic hepatoblastoma who is otherwise a suitable candidate for liver transplantation may be registered as a Status 2B on the UNOS Patient Waiting List. 3.6.4.5 Status Verification for Potential Liver Recipients. As a condition for liver acceptance, it is the responsibility of the accepting surgeon to verify the status of the candidate for whom the liver is offered. If it is determined that the actual status of the candidate is lower than the UNOS waiting list status by which the offer was made, then the procuring OPO shall be notified and the points for the candidate in question shall be re-calculated after the candidate's waiting list status has been appropriately downgraded. 3.6.5 Center Contact and Acceptance. Livers shall be offered in descending computer print-out order but the offering calls may be made concurrently (e.g., 5 liver teams may be called and given donor information provided that each team is told its priority number for the liver offer). Policy 3.4.1 (Time Limit for Acceptance) assures that each team will know within one hour whether or not another center with a patient who has higher points has accepted or rejected the offer. 3.6.6 Removal of Liver Transplant Candidates from Liver Waiting Lists When Transplanted or Deceased. If a liver transplant candidate on the UNOS Patient Waiting List has received a transplant from a cadaveric or living donor, or has died while awaiting a transplant, the listing center, or centers if the patient is multiple listed, shall immediately remove that patient from all liver waiting lists and shall notify UNOS within 24 hours of the event. If the liver recipient is again added to a liver waiting list, waiting time shall begin as of the date and time the patient is relisted. 3.6.7 UNOS Organ Center Assistance with Liver Allocation. It is recommended that the UNOS Organ Center be notified when a liver donor is identified and provided all clinical information that is necessary to offer the liver to potential recipients on the UNOS Patient Waiting List. Upon request by the OPO, the Organ Center shall attempt to locate a liver recipient on the UNOS Patient Waiting List or identify backup recipients for the liver. 3.6.8 Local Conflicts. Regarding allocation of livers, locally unresolvable inequities or conflicts that arise from prevailing OPO policies may be submitted by any interested local member for review and adjudication to the UNOS Liver and Intestinal Organ Transplantation Committee and Board of Directors. 3.6.9 Minimum Information for Liver Offers. Essential Information Category. When the Host OPO or donor center provides the following donor information, with the exception of pending serologies, to a recipient center, the recipient center must respond to the offer within one hour pursuant to UNOS Policy 3.4.1 (Time Limit for Acceptance); however, this requirement does not preclude the Host OPO from notifying a recipient center prior to this information being available: (i) Donor name and UNOS I.D. number, age, sex, race, height and weight; (ii) ABO type; (iii) Cause of brain death/diagnosis; (iv) History of treatment in hospital including current medications, vasopressors and hydration; (v) Current history of hypotensive episodes, urine output and oliguria; (vi) Indications of sepsis; (vii) Social and drug activity histories; (viii) Vital signs including blood pressure, heart rate and temperature; (ix) Other laboratory tests within the past 12 hours including: (1) Bilirubin (2) SGOT/AST (3) PT (4) BUN (5) Electrolytes (6) WBC (7) HH (8) Creatinine; (x) Arterial blood gas results; (xi) Pre- or post-transfusion serologies for HIV, hepatitis, CMV, HTLV and VDRL/RPR. 3.6.10 Allocation of Livers for Other Methods of Hepatic Support. A liver shall not be utilized for other methods of hepatic support prior to being offered first for transplantation. Prior to being utilized for other methods of hepatic support, the liver shall be offered by the UNOS Organ Center in descending point order to all Status 1 candidates, Status 2A candidates, and ABO-compatible Status 2B candidates in the Host OPO's region followed by Status 1 candidates, Status 2A candidates, and ABO-compatible Status 2B candidates in all other regions. If the liver is not accepted for transplantation within 6 hours of attempted placement by the Organ Center, the Organ Center shall offer the liver to Status 1 and Status 2A candidates for whom the liver will be considered for other methods of hepatic support. Livers allocated for other methods of hepatic support shall be offered first locally, then regionally, and then nationally in descending point order to transplant candidates designated for other methods of hepatic support. 3.6.11 Allocation of Livers for Segmental Transplantation. A transplant center that accepts a liver for segmental transplantation may allocate the remaining segment to any medically-appropriate candidate on the UNOS Patient Waiting List. If the segment is not allocated for transplantation, it should be offered for other methods of hepatic support as stated in Policy 3.6.10. HOME | About | Newsroom | Patients | Data | Resources | Links | Search | Contact Copyright © 1998, United Network for Organ Sharing all rights reserved. unos > Dah!! > I just realized it was Roy that posted unos web page and it is > unos.org. I did get in but have having a little trouble finding the > points part. > Peg > > > ------------------------------------------------------------------------ > GET WHAT YOU DESERVE! A NextCard Platinum VISA: DOUBLE Rewards points, > NO annual fee & rates as low as 9.9% FIXED APR. Apply online today! > http://clickhere./click/606 > > > eGroups.com home: /group/ > - Simplifying group communications > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 18, 1999 Report Share Posted August 18, 1999 Roy, Thanks, I was able to get into it and print it yesterday. I don't understand how they come up with the points. They said they don't up the status for cronic infections but that is what Phil's liver specialist said would get him on the list. Do they give points for the elevated LFTS for each incident that Phil was in the hospital or for current LFTS only. When I look at this it doesn't seem like Phil will get listed but the doctor made it seem like he will. We don't expect anything more than a 3 status but would like to at least get him listed. I guess we'll find out more on Sept 3rd when we see the liver doctor again. I haven't been keeping up with the LFTs that have been periodically taken so I don't have too much to compare it with. When he was in the hospital for the 10 days his biliruben was 4, I think and they had a real hard time getting it down. He has been jaundice 3 times since within 3 months but the other times they were able to get control of it within 3 days of hospitalization and IV antibiotics. Peg Roy Toutant wrote: Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 18, 1999 Report Share Posted August 18, 1999 PSC patients have a lot of ups and downs and this includes the LFTs. I don't know what the exact interpretation of the rules are, but I think if a patient is sick enough at any point in time, they can be listed at that time. If they get a lot better then I guess they can take you off the list but I doubt this happens much. I do know there are strict rules for 2B listing, if the patient gets better they have to be bumped back to a 3. Roy T. Re: unos > Roy, > Thanks, I was able to get into it and print it yesterday. I don't understand > how they come up with the points. They said they don't up the status for cronic > infections but that is what Phil's liver specialist said would get him on the > list. Do they give points for the elevated LFTS for each incident that Phil was > in the hospital or for current LFTS only. When I look at this it doesn't seem > like Phil will get listed but the doctor made it seem like he will. We don't > expect anything more than a 3 status but would like to at least get him listed. > I guess we'll find out more on Sept 3rd when we see the liver doctor again. I > haven't been keeping up with the LFTs that have been periodically taken so I > don't have too much to compare it with. When he was in the hospital for the 10 > days his biliruben was 4, I think and they had a real hard time getting it > down. He has been jaundice 3 times since within 3 months but the other times > they were able to get control of it within 3 days of hospitalization and IV > antibiotics. > Peg > > Roy Toutant wrote: > > > > ------------------------------------------------------------------------ > Just Tell Us What You Want... > Respond.com - Shopping the World for You! > http://clickhere./click/738 > > > eGroups.com home: /group/ > - Simplifying group communications > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 18, 1999 Report Share Posted August 18, 1999 Peg - I'm in the same boat as Phil. Listed because of the infections. By UNOS guides I don't have enough symptoms to be listed but the infections count because they can be fatal. Last time I saw my doctor he said that I was status 3, will be hospitalized for all future infections so they can change my status to 2B. If a liver becomes available they will do the tx while I'm in the hospital. If I recover and go release I go back to status 3. This is a little bit contradictory to what he said during my last hospital stay so I have to clarify that when I see him again in October. One other factor in this is your doctor's ability to make your case. In some cases the doctor has to go to bat for the patient and really persuade the procurement center and other tx centers that his patient needs the liver more than others. Russ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 19, 1999 Report Share Posted August 19, 1999 Russ, I really trust Phil's doctors to go to bat for him. He just got approved for ss disability. He applied about a month ago. We were told that everyone gets turned down the first time. He didn't get turned down. They back dated it to November of last year (there is a 5 month waiting period) so he was eligible as of May. He signed up for auto deposit and when he went to the bank yesterday there was the amount they told him he would get (accumulated from May) in our checking account. We haven't received anything that said he was approved but there is noone else out there putting money in our bank account. This for sure is God's work. We are having the man he sold his house to - sueing us, and the accountant chasing us for money he can seem to collect from his other partners for closing the business when he sold it. Boy have our prayers been answered. Phil is able to go on disability because I am working but it's still very hard because I make less than half of what he earned so even with the disability it's hard to make ends meet and all these people keep hounding us for money. We keep saying " What part of -WE DON'T HAVE ANY don't you understand? " Well enough complaining. God is watching over us and as Jacquelyn says " In his own good time " he will make a liver available to Phil when he needs it. Next Monday will be 5 months since Phil's last cholangitis attack. He has a couple of times we thought he was headed for one but fortunately the next day he was okay. Phil has the tiredness everyday cholangitis or not and is having a lot of pain in between his shoulder blades and having to take pain killers for it. Peg Russ Askren wrote: > Peg - > > I'm in the same boat as Phil. Listed because of the infections. By UNOS > guides I don't have enough symptoms to be listed but the infections count > because they can be fatal. > > Last time I saw my doctor he said that I was status 3, will be hospitalized > for all future infections so they can change my status to 2B. If a liver > becomes available they will do the tx while I'm in the hospital. If I > recover and go release I go back to status 3. This is a little bit > contradictory to what he said during my last hospital stay so I have to > clarify that when I see him again in October. > > One other factor in this is your doctor's ability to make your case. In > some cases the doctor has to go to bat for the patient and really persuade > the procurement center and other tx centers that his patient needs the > liver more than others. > > Russ > > ------------------------------------------------------------------------ > ebates.com. Earn up to 25% cash back for shopping online at 75 stores > like Borders, CDNow and Beyond.com. Refer a friend and earn even more! > http://clickhere./click/690 > > eGroups.com home: /group/ > - Simplifying group communications Quote Link to comment Share on other sites More sharing options...
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