Once you are accepted for transplantation, you will be put on the “Candidate waiting list” and the search for a suitable donor begins. All patients are entered onto the national transplant waiting list maintained by The United Network for Organ Sharing (UNOS), a national organization that works 24 hours a day, 365 days a year to match donors to recipients. In order to fairly and efficiently distribute this scarce resource, the country is divided into regions, so most of the organs that come to Mount Sinai are from donors in New York State.

The amount of time you spend on the waiting list is determined by many factors including blood type and the urgency of your condition. Unfortunately, due to the shortage of donor organs, the waiting time can be long and it is very important that during this time you do your best to maintain good health.

What is UNOS?
UNOS is a non-profit organization that regulates and maintains the nation’s cadaveric (from a person who is brain dead, but whose organs are still viable) organ transplant waiting list. The Organ Procurement and Transplantation Network (OPTN) was established by Congress to ensure that donated organs are fairly distributed regardless of an individual’s age, sex, ethnicity, religion, lifestyle or social status through UNOS. Both UNOS and OPTN are regulated by the U.S. Department of Health and Human Services. As of February 27, 2002, UNOS implemented the Model for End-Stage Liver Disease (MELD) scoring system for cadaveric liver allocation. UNOS mandates that all transplant centers nationwide use this new policy.

What is the MELD Scoring System?
The MELD scoring system was developed as a way to predict the likelihood of death within three months for people with advanced liver disease. One of the major responsibilities of the OPTN is to develop and implement new policies that will ensure that scarce donor organs are allocated to the patients that are medically in greatest need of a liver transplant. The idea behind MELD is that organs will be allocated more fairly because medical urgency is emphasized, while waiting time becomes less important than it had been.

How will a MELD score be assigned?
The MELD score will be calculated by using a mathematical equation that involves the following laboratory data:

• Creatinine – is an end product of metabolism that is used to monitor kidney function. Normal range is less than 1.2 mg/dL. Value becomes abnormally elevated with kidney dysfunction that is associated with advanced liver disease. If a patient is receiving dialysis as a result of kidney failure, they will be assigned a maximum creatinine of four mg/dL.
• INR - is a laboratory value used to help determine the liver’s ability for making clotting factors and a patient’s risk for bleeding. If prolonged, it is an indication that the liver disease is progressing. Normal range is less than 1.2.
• Bilirubin - is an indicator of the liver’s ability to detoxify the blood. It's what makes a person appear jaundiced (yellowing of the skin and white of the eyes). When elevated it can cause an individual to feel itchy. Normal range for total bilirubin is 0.1-1.2mg/dL.

A MELD score can range from 6-40 points. The higher the MELD score, the more frequently you will be required to have laboratory blood tests. Organs will be now be allocated to the patient with the highest MELD score versus the patient who has the longest time on the waiting list. If there are two patients with the same MELD score, then time waiting at that particular score will be used as a “tie breaker.” Please note that you will be required to have your laboratory blood tests done here at Mount Sinai Hospital.

Make sure that you have an appointment for either a follow up visit in our office or for lab work before your MELD recertification is due. If you let your MELD recertification lapse past the due date, you MELD will automatically be downgraded by UNOS. If you do not have an appointment or need one, contact your coordinator assistant immediately for one.

After the donor liver is evaluated by the transplant surgical team and the recipient is informed about the suitability of the donor liver, the patient will be taken to the operating room for transplant operation.

Liver transplant surgery is extremely complex and may last 6-12 hours, depending upon the patient’s condition.

Transplant surgery occurs in four stages:

1. Removal of the recipient’s diseased liver from its bed.
2. Placement of the new liver and making vascular connections between donor liver and recipient vessels.
3. Removal of the vascular clamps and establishment of the blood flow into liver which is called “reperfusion.”
4. The last step is the reconstruction of the biliary tract. This can be done either connecting donor’s and recipient’s bile ducts or creating isolated intestinal loop to connect the donor bile duct

Pediatric Liver Transplant Program at Mount Sinai provides leading-edge care for children with liver disease. The program continues to undergo significant growth and is recognized as one of the leading centers in the country.

Between 2002 and 2004, 75 isolated pediatric liver transplants were performed in 71 children. 17 of the 39 transplants performed in the year 2000 were living-related donor, including four for fulminant (rapid onset) hepatic failure. One-year survival rate is 98 percent, second highest in the nation. Five-year survival rate is 92 percent. Outpatient activity of the program includes 1,800 outpatient visits with 150 new consultations.

A wide spectrum of academic and research activities keeps the pediatric liver transplant program on the leading edge of discovery. Articles based on the work of physicians and researchers on our staff have appeared in leading medical publications such as Gastroenterology, Transplantation, Pediatrics, The Journal of Pediatrics, Liver Transplantation, Hepatology, and Pediatric Transplantation.

Important Highlights

• Youngest transplant recipient - 17 days old
• 10 combined liver/kidney transplants
• First living related liver/kidney transplant from the same donor for oxalosis
• SPLIT liver transplant between two pediatric recipients including in-situ split liver transplantation
• 22 living related transplants for Fulminant (rapid onset) liver failure

Organs for transplantation are usually obtained from cadaver donors, after their families give permission. But there are not enough cadaver donor organs available for everyone who needs one, and as a result, increasing numbers of patients are being added to the transplant waiting list. Because of the organ shortage, many patients waiting for livers die while on the waiting list or become too sick to undergo a transplant. But if a patient can receive a piece of liver from a relative or friend, he or she need not wait for a cadaver organ. Thus, living donor liver transplantation can be an important alternative for many patients.

In living donor liver transplantation, a piece of liver is surgically removed from a living person and transplanted into a recipient, immediately after the recipient’s diseased liver has been entirely removed.

Living donor liver transplantation is possible because the liver — unlike any other organ in the body — has the ability to regenerate, or grow. Regeneration of the liver happens over a very short period – possibly days to weeks, and certainly within 6-8 weeks. So when surgeons remove a piece of the donor’s liver, the part that remains in the donor grows back quickly to its original size.

More than a decade ago, surgeons around the world began to perform these procedures using adult donors for children who needed transplants. In addition, surgeons gained experience in splitting a single cadaver liver into two pieces, for transplantation into two recipients. Mount Sinai surgeons have been at the forefront of these surgical advances. They have also pioneered the use of living donor liver transplants in adult recipients, safely removing the larger right lobe of the donor’s liver.

There are many benefits to living donor liver transplantation, including a lower risk of rejection and the ability to schedule surgery electively, rather than on an emergency basis, once a cadaveric donor liver becomes available. There is also an important emotional benefit that comes from knowing that a loved one or perhaps a kind stranger has made a ‘gift of life.’ Mount Sinai has developed an independent donor advocacy team for the purpose of ensuring the highest standards of safety and ethics are always in place. This team consists of an independent gastroenterologist, an independent transplant surgeon, a liver transplant coordinator, a social worker and a psychiatrist.