Medical urgency is assigned to a pediatric liver transplant patient (less than 18 years of age) based on the criteria defined as follows.

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. 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, 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; b) 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; 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 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 deviation score of expected growth (height or weight) and requiring initiation of parenteral nutritional support, or nasogastric feedings to supply a minimum of 30% of caloric needs.	
Note:	This criterion defines growth failure as either < 5th percentile for weight and/or height, or loss of 1.5 standard deviation score of expected growth (height or weight). The first measure looks at relative growth as of a single point in time. The second alternative accounts for cases in which a substantial loss in growth occurs between two points in time. Assessment of growth failure using the standard deviation score decrease can be derived by, first, measuring (or using a measure of) the patient’s growth at two different times, second, calculating the patient’s growth velocity between these times, and, third, using the growth velocity to calculate the standard deviation score (i.e., (patient’s growth rate - mean growth rate for age and sex) divided by standard deviation of growth rate for age and sex).	
(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 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 Wilson'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; b) 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.	

A pediatric liver transplant candidate with Ornithinine 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.

A patient with hepatocellular carcinoma may be registered as a Status 2B if the patient meets all of the following medical criteria:
(i) The patient has known hepatocellular carcinoma 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 hepatocellular carcinoma in accordance with the modified Tumor-Node-Metastasis (TNM) classification, 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 hepatocellular carcinoma 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.
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.