The Final Rule which was later published in 1999 elaborated the national framework for matching, allocation and distribution of the donated organs. The medical criteria were put in place to ensure justice and reinforce equity. The National Organ Transplant Act published in 1984 indicates UNOS to establish medical criteria when organs are being allocated. It is crucial not to discriminate transplantation on age, gender, ethnicity and socioeconomic backgrounds. The two primary goals of OPTN/UNOS are (1) The equitable distribution of donated orangs and (2) The appropriate care of minority candidates. In Europe, the Eurotransplant network is responsible for organ procurement and allocation. Similar to UNOS, National Health Service Blood and Transplant is responsible for the matching, procurement and allocation of organ transplantation in the United Kingdom. In 2000, “the Final Rule” was published by the United States Department of Health and Human Services establishing federal regulations on OPTN policies including listing requirements, organ procurement, identification of organ recipient, allocation of donated organs, designated transplant program requirements, reviews, evaluation and enforcement of transplant programs. UNOS was first established by the United States Congress via the National Organ Transplant Act in 1984. UNOS is a not-for-profit and scientific organization which manages the Organ Procurement and Transplantation Network (OPTN), the sole network which is responsible for procuring, matching and allocating donated human organs in the United States by maintaining the national organ transplant database (UNet). In the United States, organ transplantation is regulated by the United Network OF Organ Sharing (UNOS). Finally, we reviewed the liver transplant waitlist, donation and survival outcomes in the United States. We then reviewed the standard and non-standard indications for MELD exceptions and the decision-making process of the National Review Liver Review Board. We reviewed the disadvantages of the DSA-based allocation policies and the advantages of the newest acuity circle allocation model. Prior to the current and most recent policy, livers from adult donors were matched first to the status 1A/1B patients located within the boundaries of the UNOS regions and donor-service areas (DSA). MELD-Sodium score was implemented for liver allocation policy in 2016. The priority assignment of MELD-sodium score resulted in LT and prevented mortality on waitlist. The serum sodium is the independent indicator of mortality risk in patients with chronic liver disease. After 2002, UNOS changed its allocation policy based on model for end-stage liver disease (MELD) score. Prior to 2002, UNOS used Child-Turcotte-Pugh score to list and stratify patients for liver transplantation (LT). We reviewed the evolution of liver transplant allocation policies. The donor liver organs are matched, allocated and procured by the Organ Procurement and Transplantation Network which is administered by the United Network of Organ Sharing (UNOS), a not-for-profit organization governed by the United States human health services. Liver transplant allocation policies in the United States has evolved over 3 decades.
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