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RecordsAdult Kidney Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Surgeon Name:
NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Functional Status:
Physical Capacity:
No Limitationsnmlkj
Limited Mobilitynmlkj
Wheelchair bound or more limitednmlkj
Not Applicable (< 1 year old or hospitalized)nmlkj
Unknownnmlkj
Working for income: YES NO UNKnmlkj nmlkj nmlkj
If No, Not Working Due To:
If Yes:
Working Full Timenmlkj
Working Part Time due to Demands of Treatmentnmlkj
Working Part Time due to Disabilitynmlkj
Working Part Time due to Insurance Conflictnmlkj
Working Part Time due to Inability to Find Full Time Worknmlkj
Working Part Time due to Patient Choicenmlkj
Working Part Time Reason Unknownnmlkj
Working, Part Time vs. Full Time Unknownnmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Unable to participate regularly in academics due to dialysisnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Pretransplant Dialysis: YES NO UNKnmlkj nmlkj nmlkj
If Yes, Date of Most Recent Initiation of ChronicMaintenance Dialysis: ST=
Serum Creatinine at Time of Tx: mg/dl ST=
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Was preimplantation kidney biopsy performed at thetransplant center: YES NOnmlkj nmlkj
Did patient receive any pretransplant bloodtransfusions: YES NO UNKnmlkj nmlkj nmlkj
Any tolerance induction technique used: YES NO UNKnmlkj nmlkj nmlkj
Previous Pregnancies:
NO PREVIOUS PREGNANCYnmlkj
1 PREVIOUS PREGNANCYnmlkj
2 PREVIOUS PREGNANCIESnmlkj
3 PREVIOUS PREGNANCIESnmlkj
4 PREVIOUS PREGNANCIESnmlkj
5 PREVIOUS PREGNANCIESnmlkj
MORE THAN 5 PREVIOUS PREGNANCIESnmlkj
NOT APPLICABLE: < 10 years oldnmlkj
UNKNOWNnmlkj
(which may or may not have resulted in a live birth)
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Type:
Kidney Preservation Information:
Total Cold ischemia Time Right KI(OR EN-BLOC): (ifpumped, include pump time):
hrs ST=
Total Warm Ischemia Time Right KI (OR EN-BLOC):(Include Anastomotic time):
min ST=
Total Cold ischemia Time Left KI (if pumped, includepump time):
hrs ST=
Total Warm ischemia Time Left KI (include Anastomotictime):
min ST=
Kidney(s) received on:
Icenmlkj
Pumpnmlkj
N/Anmlkj
Received on ice:Stayed on icenmlkj
Put on pumpnmlkj
Received on pump:Stayed on pumpnmlkj
Put on icenmlkj
If put on pump or stayed on pump:
Final resistance at transplant: ST=
Final flow rate at transplant: ST=
Incidental Tumor found at time of Transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, specify tumor type:
Oncocytomanmlkj
Renal Cell Carcinomanmlkj
Carcinoidnmlkj
Adenomanmlkj
Transitional Cell Carcinomanmlkj
Other Primary Kidney Tumor, Specify.nmlkj
Specify:
Clinical Information : POST TRANSPLANT
Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Resumed Maintenance Dialysis: YES NOnmlkj nmlkj
Date Maintenance Dialysis Resumed:
Select a Dialysis Provider:
Provider #:
Provider Name:
Date of Graft Failure:
Primary Cause of Graft Failure:
HYPERACUTE REJECTIONnmlkj
ACUTE REJECTIONnmlkj
PRIMARY FAILUREnmlkj
GRAFT THROMBOSISnmlkj
INFECTIONnmlkj
SURGICAL COMPLICATIONSnmlkj
UROLOGICAL COMPLICATIONSnmlkj
RECURRENT DISEASEnmlkj
OTHER SPECIFY CAUSEnmlkj
Specify:
Contributory causes of graft failure:
Acute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Graft Thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Infection: YES NO UNKnmlkj nmlkj nmlkj
Surgical Complications: YES NO UNKnmlkj nmlkj nmlkj
Urological Complications: YES NO UNKnmlkj nmlkj nmlkj
Recurrent Disease: YES NO UNKnmlkj nmlkj nmlkj
Other, Specify:
Most Recent Serum Creatinine Prior to Discharge: mg/dl ST=
Kidney Produced > 40ml of Urine in First 24 Hours: YES NOnmlkj nmlkj
Patient Need Dialysis within First Week: YES NOnmlkj nmlkj
Creatinine decline by 25% or more in first 24 hours on 2separate samples: YES NOnmlkj nmlkj
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
RecordsAdult Kidney-Pancreas Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Surgeon Name:
NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Kidney Primary Diagnosis:
Specify:
Pancreas Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Retransplanted organ: Kidney Pancreas Kidney/Pancreasnmlkj nmlkj nmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Functional Status:
Physical Capacity:
No Limitationsnmlkj
Limited Mobilitynmlkj
Wheelchair bound or more limitednmlkj
Not Applicable (< 1 year old or hospitalized)nmlkj
Unknownnmlkj
Working for income: YES NO UNKnmlkj nmlkj nmlkj
If No, Not Working Due To:
If Yes:
Working Full Timenmlkj
Working Part Time due to Demands of Treatmentnmlkj
Working Part Time due to Disabilitynmlkj
Working Part Time due to Insurance Conflictnmlkj
Working Part Time due to Inability to Find Full Time Worknmlkj
Working Part Time due to Patient Choicenmlkj
Working Part Time Reason Unknownnmlkj
Working, Part Time vs. Full Time Unknownnmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Academic Activity Level:
Unable to participate regularly in academics due to dialysisnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Kidney Source of Payment:
Primary:
Specify:
Secondary:
Pancreas Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Height: ft. in. cm ST=
Weight: kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Pretransplant Dialysis: YES NO UNKnmlkj nmlkj nmlkj
If Yes, Date of Most Recent Initiation of ChronicMaintenance Dialysis: ST=
Average Daily Insulin Units: ST=
Serum Creatinine at Time of Tx: mg/dl ST=
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Was preimplantation kidney biopsy performed at thetransplant center: YES NOnmlkj nmlkj
Did patient receive any pretransplant bloodtranfusions: YES NO UNKnmlkj nmlkj nmlkj
Any tolerance induction technique used: YES NO UNKnmlkj nmlkj nmlkj
Previous Pregnancies:
NO PREVIOUS PREGNANCYnmlkj
1 PREVIOUS PREGNANCYnmlkj
2 PREVIOUS PREGNANCIESnmlkj
3 PREVIOUS PREGNANCIESnmlkj
4 PREVIOUS PREGNANCIESnmlkj
5 PREVIOUS PREGNANCIESnmlkj
MORE THAN 5 PREVIOUS PREGNANCIESnmlkj
NOT APPLICABLE: < 10 years oldnmlkj
UNKNOWNnmlkj
(which may or may not have resulted in a live birth)
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Type:
Surgical Information:
Was the Pancreas revascularized before or after otherorgans:
Beforenmlkj
Simultaneousnmlkj
Afternmlkj
Not Applicablenmlkj
Surgical Incision:
Iliac Fossa PA left/KI rightnmlkj
Iliac Fossa PA right/KI leftnmlkj
Leftnmlkj
Midlinenmlkj
Rightnmlkj
Graft Placement:
INTRA-PERITONEALnmlkj
RETRO-PERITONEALnmlkj
PARTIAL INTRA/RETRO-PERITONEALnmlkj
Operative Technique:
Simultaneous Kidney-Pancreasnmlkj
Clusternmlkj
Multi-Organ Non-Clusternmlkj
Duct Management:
ENTERIC W/ROUX-EN-Ynmlkj
ENTERIC W/O ROUX-EN-Ynmlkj
CYSTOSTOMYnmlkj
DUCT INJECTION IMMEDIATEnmlkj
DUCT INJECTION DELAYEDnmlkj
OTHER SPECIFYnmlkj
Specify:
Venous Vascular Management:
SYSTEMIC SYSTEM (ILIAC:CAVA)nmlkj
PORTAL SYSTEM (PORTAL OR TRIBUTARIES)nmlkj
NA/Multi-organ clusternmlkj
Arterial Reconstruction:
CELIAC WITH PANCREASnmlkj
Y-GRAFT TO SPA & SMAnmlkj
SPA TO SMA DIRECTnmlkj
SPA TO SMA WITH INTERPOSITIONnmlkj
SPA ALONEnmlkj
OTHER SPECIFYnmlkj
Specify:
Venous Extension Graft: YES NOnmlkj nmlkj
Kidney and Pancreas Preservation Information:
Total Cold ischemia Time Right KI(OR EN-BLOC): (ifpumped, include pump time):
hrs ST=
Total Warm Ischemia Time Right KI (OR EN-BLOC):(Include Anastomotic time):
min ST=
Total Cold Ischemia Time Left KI (If pumped, includepump time):
hrs ST=
Total Warm ischemia Time Left KI (Include Anastomotictime):
min ST=
Total Pancreas Preservation Time (include Cold, Warm,Anastomotic time):
hrs ST=
Kidney(s) received on:
Icenmlkj
Pumpnmlkj
N/Anmlkj
Received on ice:Stayed on icenmlkj
Put on pumpnmlkj
Received on pump:Stayed on pumpnmlkj
Put on icenmlkj
If put on pump or stayed on pump:
Final resistance at transplant: ST=
Final flow rate at transplant: ST=
Incidental Tumor found at time of Transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, specify tumor type:
Oncocytomanmlkj
Renal Cell Carcinomanmlkj
Carcinoidnmlkj
Adenomanmlkj
Transitional Cell Carcinomanmlkj
Other Primary Kidney Tumor, Specify.nmlkj
Specify:
Clinical Information : POST TRANSPLANT
Kidney Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Resumed Maintenance Dialysis: YES NOnmlkj nmlkj
Date Maintenance Dialysis Resumed:
Select a Dialysis Provider:
Provider #:
Provider Name:
Kidney Date of Graft Failure:
Kidney Primary Cause of Graft Failure:
HYPERACUTE REJECTIONnmlkj
ACUTE REJECTIONnmlkj
PRIMARY FAILUREnmlkj
GRAFT THROMBOSISnmlkj
INFECTIONnmlkj
SURGICAL COMPLICATIONSnmlkj
UROLOGICAL COMPLICATIONSnmlkj
RECURRENT DISEASEnmlkj
OTHER SPECIFY CAUSEnmlkj
Specify:
Contributory causes of graft failure:
Kidney Acute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Kidney Graft Thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Kidney Infection: YES NO UNKnmlkj nmlkj nmlkj
Surgical Complications: YES NO UNKnmlkj nmlkj nmlkj
Urological Complications: YES NO UNKnmlkj nmlkj nmlkj
Recurrent Disease: YES NO UNKnmlkj nmlkj nmlkj
Other, Specify:
Did patient have any acute kidney rejection episodesbetween transplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Most Recent Serum Creatinine Prior to Discharge: mg/dl ST=
Kidney Produced > 40ml of Urine in First 24 Hours: YES NOnmlkj nmlkj
Patient Need Dialysis within First Week: YES NOnmlkj nmlkj
Creatinine Decline by 25% or More in First 24 Hours on 2separate samples: YES NOnmlkj nmlkj
Pancreas Graft Status: Functioning Partial Function Failednmlkj nmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Method of blood sugar control: (check all that apply)
Insulingfedc
Oral medicationgfedc
Dietgfedc
No Treatmentgfedc
Date Insulin/Medication Resumed:
Pancreas Date of Graft Failure:
Pancreas Graft Removed: YES NO UNKnmlkj nmlkj nmlkj
If Yes, Date Pancreas Graft Removed:
Pancreas Primary Cause of Graft Failure:
Pancreas Primary Cause of Graft Failure/Specify:
Contributory causes of graft failure:
Pancreas Graft/Vascular Thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Pancreas Infection: YES NO UNKnmlkj nmlkj nmlkj
Bleeding: YES NO UNKnmlkj nmlkj nmlkj
Anastomotic Leak: YES NO UNKnmlkj nmlkj nmlkj
Hyperacute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Pancreas Acute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Biopsy Proven Isletitis: YES NO UNKnmlkj nmlkj nmlkj
Pancreatitis: YES NO UNKnmlkj nmlkj nmlkj
Other, Specify:
Did patient have any acute pancreas rejection episodesbetween transplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Pancreas Transplant Complications:
(Not leading to graft failure.)
Pancreatitis: YES NO UNKnmlkj nmlkj nmlkj
Anastomotic Leak: YES NO UNKnmlkj nmlkj nmlkj
Abscess or Local Infection: YES NO UNKnmlkj nmlkj nmlkj
Other:
Weight Post Transplant: lbs. kg ST=
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin
gfedc
gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab
gfedc
gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
RecordsAdult Pancreas Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Surgeon Name:
NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Functional Status:
Physical Capacity:
No Limitationsnmlkj
Limited Mobilitynmlkj
Wheelchair bound or more limitednmlkj
Not Applicable (< 1 year old or hospitalized)nmlkj
Unknownnmlkj
Working for income: YES NO UNKnmlkj nmlkj nmlkj
If No, Not Working Due To:
If Yes:
Working Full Timenmlkj
Working Part Time due to Demands of Treatmentnmlkj
Working Part Time due to Disabilitynmlkj
Working Part Time due to Insurance Conflictnmlkj
Working Part Time due to Inability to Find Full Time Worknmlkj
Working Part Time due to Patient Choicenmlkj
Working Part Time Reason Unknownnmlkj
Working, Part Time vs. Full Time Unknownnmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Pretransplant Dialysis: YES NO UNKnmlkj nmlkj nmlkj
If Yes, Date of Most Recent Initiation of ChronicMaintenance Dialysis: ST=
Average Daily Insulin Units: ST=
Serum Creatinine at Time of Tx: mg/dl ST=
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Positivenmlkj
Negativenmlkj
HBV Surface Antigen:Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Type:
Surgical Information:
If a simultaneous Tx with another organ, was thePancreas revascularized before or after other organs:
Beforenmlkj
Simultaneousnmlkj
Afternmlkj
Not Applicablenmlkj
Surgical Incision:
Leftnmlkj
Midlinenmlkj
Othernmlkj
Rightnmlkj
Graft Placement:
INTRA-PERITONEALnmlkj
RETRO-PERITONEALnmlkj
PARTIAL INTRA/RETRO-PERITONEALnmlkj
Operative Technique:
PANCREAS ALONEnmlkj
CLUSTERnmlkj
MULTI-ORGAN NON-CLUSTERnmlkj
PANCREAS AFTER KIDNEYnmlkj
PANCREAS WITH KIDNEY DIFFERENT DONORnmlkj
Duct Management:
ENTERIC W/ROUX-EN-Ynmlkj
ENTERIC W/O ROUX-EN-Ynmlkj
CYSTOSTOMYnmlkj
DUCT INJECTION IMMEDIATEnmlkj
DUCT INJECTION DELAYEDnmlkj
OTHER SPECIFYnmlkj
Specify:
Venous Vascular Management:
SYSTEMIC SYSTEM (ILIAC:CAVA)nmlkj
PORTAL SYSTEM (PORTAL OR TRIBUTARIES)nmlkj
NA/Multi-organ clusternmlkj
Arterial Reconstruction:
CELIAC WITH PANCREASnmlkj
Y-GRAFT TO SPA & SMAnmlkj
SPA TO SMA DIRECTnmlkj
SPA TO SMA WITH INTERPOSITIONnmlkj
SPA ALONEnmlkj
OTHER SPECIFYnmlkj
Specify:
Venous Extension Graft: YES NOnmlkj nmlkj
Preservation Information:
Total Pancreas Preservation Time (include Cold, Warm,Anastomotic time):
hrs ST=
Clinical Information : POST TRANSPLANT
Pancreas Graft Status: Functioning Partial Function Failednmlkj nmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Method of blood sugar control: (check all that apply)
Insulingfedc
Oral medicationgfedc
Dietgfedc
No Treatmentgfedc
Date insulin/medication first resumed:
Date of Graft Failure:
Pancreas Graft Removed: YES NO UNKnmlkj nmlkj nmlkj
Date Pancreas Graft Removed:
Pancreas Primary Cause of Graft Failure:
Specify:
Contributory causes of graft failure:
Pancreas Graft/Vascular Thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Pancreas Infection: YES NO UNKnmlkj nmlkj nmlkj
Bleeding: YES NO UNKnmlkj nmlkj nmlkj
Anastomotic Leak: YES NO UNKnmlkj nmlkj nmlkj
Hyperacute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Pancreas Acute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Biopsy Proven Isletitis: YES NO UNKnmlkj nmlkj nmlkj
Pancreatitis: YES NO UNKnmlkj nmlkj nmlkj
Other, Specify:
Pancreas Transplant Complications:
(Not leading to graft failure.)
Pancreatitis: YES NO UNKnmlkj nmlkj nmlkj
Anastomotic Leak: YES NO UNKnmlkj nmlkj nmlkj
Abscess or Local Infection: YES NO UNKnmlkj nmlkj nmlkj
Pancreas Transplant Complications: Other
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications that
were prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
RecordsAdult Liver Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Surgeon Name:
NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Patient on Life Support: YES NOnmlkj nmlkj
Ventilatorgfedc
Artificial Livergfedc
Other Mechanism, Specifygfedc
Specify:
Functional Status:
Physical Capacity:
No Limitationsnmlkj
Limited Mobilitynmlkj
Wheelchair bound or more limitednmlkj
Not Applicable (< 1 year old or hospitalized)nmlkj
Unknownnmlkj
Working for income: YES NO UNKnmlkj nmlkj nmlkj
If No, Not Working Due To:
If Yes:
Working Full Timenmlkj
Working Part Time due to Demands of Treatmentnmlkj
Working Part Time due to Disabilitynmlkj
Working Part Time due to Insurance Conflictnmlkj
Working Part Time due to Inability to Find Full Time Worknmlkj
Working Part Time due to Patient Choicenmlkj
Working Part Time Reason Unknownnmlkj
Working, Part Time vs. Full Time Unknownnmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Any tolerance induction technique used: YES NO UNKnmlkj nmlkj nmlkj
Pretransplant Lab Date:
SGPT/ALT: U/L ST=
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Hepatocellular Carcinomagfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Surgical Procedure:ORTHOTOPICnmlkj
HETEROTOPICnmlkj
Procedure Type:
Whole Livernmlkj
Partial Liver, remainder not Tx or Living Transplantnmlkj
Split Livernmlkj
Whole Liver with Pancreas (Technical Reasons)nmlkj
Partial Liver with Pancreas (Technical Reasons)nmlkj
Split Liver with Pancreas (Technical Reasons)nmlkj
Split Type:
Preservation Information:
Warm Ischemia Time (include anastomotic time): min ST=
Total Cold Ischemia Time (if pumped, include pumptime):
hrs ST=
Risk Factors:
Did Patient receive 5 or more units of packed red bloodcells within 48 hours prior to transplantation due tospontaneous portal hypertensive bleeding:
YES NO UNKnmlkj nmlkj nmlkj
Spontaneous Bacterial Peritonitis: YES NO UNKnmlkj nmlkj nmlkj
Previous Abdominal Surgery: YES NO UNKnmlkj nmlkj nmlkj
Portal Vein Thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Transjugular Intrahepatic Portacaval Stint Shunt: YES NO UNKnmlkj nmlkj nmlkj
Incidental Tumor found at time of Transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, specify tumor type:
Hepatocellular Adenomanmlkj
Hemangiomanmlkj
Hemangioendotheliomanmlkj
Angiomyolipomanmlkj
Bile Duct Cystadenocarcinomanmlkj
Cholangiocarcinomanmlkj
Hepatocellular Carcinomanmlkj
Hepatoblastomanmlkj
Angiosarcomanmlkj
Other Primary Liver Tumor, Specifynmlkj
Specify:
Clinical Information : POST TRANSPLANT
Pathology Conf. Liver Diag. of Hospital Discharge:
Specify:
Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Date of Graft Failure:
Causes of graft failure:
Primary Graft Failure YES NO UNKnmlkj nmlkj nmlkj
Vascular Thrombosis YES NO UNKnmlkj nmlkj nmlkj
Biliary Tract Complication YES NO UNKnmlkj nmlkj nmlkj
Hepatitis: DeNovo YES NO UNKnmlkj nmlkj nmlkj
Hepatitis: Recurrent YES NO UNKnmlkj nmlkj nmlkj
Recurrent Disease (non-Hepatitis) YES NO UNKnmlkj nmlkj nmlkj
Acute Rejection YES NO UNKnmlkj nmlkj nmlkj
Infection YES NO UNKnmlkj nmlkj nmlkj
Other, Specify:
Discharge Lab Date:
Total Bilirubin: mg/dl ST=
SGPT/ALT: U/L ST=
Serum Albumin: g/dl ST=
Serum Creatinine: mg/dl ST=
INR: ST=
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed under
maintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
RecordsAdult Intestine Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Surgeon Name:
NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Secondary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Patient on Life Support: YES NOnmlkj nmlkj
Ventilatorgfedc
Artificial Livergfedc
Other Mechanism, Specifygfedc
Specify:
Functional Status:
Physical Capacity:
No Limitationsnmlkj
Limited Mobilitynmlkj
Wheelchair bound or more limitednmlkj
Not Applicable (< 1 year old or hospitalized)nmlkj
Unknownnmlkj
Working for income: YES NO UNKnmlkj nmlkj nmlkj
If No, Not Working Due To:
If Yes:
Working Full Timenmlkj
Working Part Time due to Demands of Treatmentnmlkj
Working Part Time due to Disabilitynmlkj
Working Part Time due to Insurance Conflictnmlkj
Working Part Time due to Inability to Find Full Time Worknmlkj
Working Part Time due to Patient Choicenmlkj
Working Part Time Reason Unknownnmlkj
Working, Part Time vs. Full Time Unknownnmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Positivenmlkj
Negativenmlkj
HBV Core Antibody:Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Total Bilirubin: mg/dl ST=
Serum Albumin: g/dl ST=
Serum Creatinine: mg/dl ST=
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Hepatocellular Carcinomagfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Information:
Intestine Venous Drainage: Portal Systemicnmlkj nmlkj
Native Viscera Venous Drainage: Portal Systemicnmlkj nmlkj
Procedure Type:
Whole Intestinenmlkj
Intestine Segmentnmlkj
Whole Intestine with Pancreas (Technical Reasons)nmlkj
Intestine Segment with Pancreas (Technical Reasons)nmlkj
Organ Type: Stomachgfedc
Small Intestinegfedc
Duodenumgfedc
Large Intestinegfedc
Preservation Information:
Total Ischemic Time (include cold, warm andanastomotic time):
hrs ST=
Risk Factors:
Recent Septicemia: YES NO UNKnmlkj nmlkj nmlkj
Exhausted Vascular Access: YES NO UNKnmlkj nmlkj nmlkj
Liver Dysfunction: YES NO UNKnmlkj nmlkj nmlkj
Previous Abdominal Surgery: YES NO UNKnmlkj nmlkj nmlkj
Number Previous Abdominal Surgeries: ST=
Dilated/Non-Functional Bowel Segments: YES NO UNKnmlkj nmlkj nmlkj
Other:
Clinical Information : POST TRANSPLANT
Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
TPN Dependent: YES NOnmlkj nmlkj
IV Dependent: YES NOnmlkj nmlkj
Oral Feeding: YES NOnmlkj nmlkj
Tube Feed: YES NOnmlkj nmlkj
Date of Graft Failure:
Primary Cause of Graft Failure:
RECURRENT TUMORnmlkj
ACUTE REJECTIONnmlkj
CHRONIC REJECTIONnmlkj
TECHNICAL PROBLEMSnmlkj
INFECTIONnmlkj
LYMPHOPROLIFERATIVE DISEASEnmlkj
OTHER SPECIFYnmlkj
Specify:
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
RecordsAdult Thoracic - Lung Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Physician Name:
Physician NPI#:
Surgeon Name:
Surgeon NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Patient on Life Support: YES NOnmlkj nmlkj
Extra Corporeal Membrane Oxygenationgfedc
Intra Aortic Balloon Pumpgfedc
Prostacyclin Infusiongfedc
Prostacyclin Inhalationgfedc
Inhaled NOgfedc
Ventilatorgfedc
Other Mechanismgfedc
Specify:
Functional Status:
Physical Capacity:
No Limitationsnmlkj
Limited Mobilitynmlkj
Wheelchair bound or more limitednmlkj
Not Applicable (< 1 year old or hospitalized)nmlkj
Unknownnmlkj
Working for income: YES NO UNKnmlkj nmlkj nmlkj
If No, Not Working Due To:
If Yes:
Working Full Timenmlkj
Working Part Time due to Demands of Treatmentnmlkj
Working Part Time due to Disabilitynmlkj
Working Part Time due to Insurance Conflictnmlkj
Working Part Time due to Inability to Find Full Time Worknmlkj
Working Part Time due to Patient Choicenmlkj
Working Part Time Reason Unknownnmlkj
Working, Part Time vs. Full Time Unknownnmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Most Recent Hemodynamics: Inotropes/Vasodilators:
PA (sys)mm/Hg:ST=
YES NOnmlkj nmlkj
PA(dia) mm/Hg:ST=
YES NOnmlkj nmlkj
PA(mean) mm/Hg:ST=
YES NOnmlkj nmlkj
PCW(mean) mm/Hg:ST=
YES NOnmlkj nmlkj
CO L/min:ST=
YES NOnmlkj nmlkj
Most Recent Serum Creatinine: mg/dl ST=
Most Recent Total Bilirubin: mg/dl ST=
Oxygen Requirement at Rest: L/min ST=
Chronic Steroid Use: YES NO UNKnmlkj nmlkj nmlkj
Pulmonary Status (Give most recent value):
FVC: %predicted: ST=
FeV1: %predicted: ST=
pCO2: mm/Hg: ST=
Events occurring between listing and transplant:
Transfusions: YES NO UNKnmlkj nmlkj nmlkj
Pulmonary Embolism: YES NO UNKnmlkj nmlkj nmlkj
Infection Requiring IV Therapy within 2 wks prior toTx: YES NO UNKnmlkj nmlkj nmlkj
Cerebrovascular Event: YES NO UNKnmlkj nmlkj nmlkj
Dialysis: YES NO UNKnmlkj nmlkj nmlkj
Implantable Defibrillator: YES NO UNKnmlkj nmlkj nmlkj
Prior Cardiac Surgery (non-transplant): YES NO UNKnmlkj nmlkj nmlkj
If yes, check all that apply:
CABGgfedc
Valve Replacement/Repairgfedc
Congenitalgfedc
Left Ventricular Remodelinggfedc
Other, specifygfedc
Specify:
Prior Lung Surgery (non-transplant): YES NO UNKnmlkj nmlkj nmlkj
If yes, check all that apply:
Pneumoreductiongfedc
Pneumothorax Surgery-Nodulegfedc
Pneumothorax Decorticationgfedc
Lobectomygfedc
Pneumonectomygfedc
Left Thoracotomygfedc
Right Thoracotomygfedc
Other, specifygfedc
Specify:
Episode of Ventilatory Support: YES NO UNKnmlkj nmlkj nmlkj
If yes, indicate most recent timeframe:
At time of transplantnmlkj
Within 3 months of transplantnmlkj
>3 months prior to transplantnmlkj
Tracheostomy: YES NO UNKnmlkj nmlkj nmlkj
NO PREVIOUS PREGNANCYnmlkj
Previous Pregnancies:
1 PREVIOUS PREGNANCYnmlkj
2 PREVIOUS PREGNANCIESnmlkj
3 PREVIOUS PREGNANCIESnmlkj
4 PREVIOUS PREGNANCIESnmlkj
5 PREVIOUS PREGNANCIESnmlkj
MORE THAN 5 PREVIOUS PREGNANCIESnmlkj
NOT APPLICABLE: < 10 years oldnmlkj
UNKNOWNnmlkj
(which may or may not have resulted in a live birth)
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Type:
SINGLE LEFT LUNGnmlkj
SINGLE RIGHT LUNGnmlkj
BILATERAL SEQUENTIAL LUNGnmlkj
EN-BLOC DOUBLE LUNGnmlkj
LOBE, RIGHTnmlkj
LOBE, LEFTnmlkj
Was this a retransplant due to failure of a previousthoracic graft: YES NOnmlkj nmlkj
Total Organ Ischemia Time (include cold, warm and anastomotic time):
Left Lung: min ST=
Right Lung (OR EN-BLOC): min ST=
Incidental Tumor found at time of Transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, specify tumor type:
Adenomanmlkj
Carcinomanmlkj
Carcinoidnmlkj
Lymphomanmlkj
Harmartomanmlkj
Other Primary Lung Tumor, Specifynmlkj
Specify:
Clinical Information : POST TRANSPLANT
Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Date of Graft Failure:
Primary Cause of Graft Failure:
Primary Non-Functionnmlkj
Acute Rejectionnmlkj
Chronic Rejection/Atherosclerosisnmlkj
Other, Specifynmlkj
Specify:
Events Prior to Discharge:
Any Drug Treated Infection: YES NO UNKnmlkj nmlkj nmlkj
Stroke: YES NO UNKnmlkj nmlkj nmlkj
Dialysis: YES NO UNKnmlkj nmlkj nmlkj
Cardiac Re-Operation: YES NO UNKnmlkj nmlkj nmlkj
Other Surgical Procedures: YES NO UNKnmlkj nmlkj nmlkj
Ventilator Support:
Nonmlkj
Ventilator support for <= 48 hoursnmlkj
Ventilator support for >48 hours but < 5 daysnmlkj
Ventilator support >= 5 daysnmlkj
Ventilator support, duration unknownnmlkj
Unknown Statusnmlkj
Reintubated: YES NO UNKnmlkj nmlkj nmlkj
Permanent Pacemaker: YES NO UNKnmlkj nmlkj nmlkj
Chest drain >2 weeks: YES NO UNKnmlkj nmlkj nmlkj
Airway Dehiscence: YES NO UNKnmlkj nmlkj nmlkj
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A)
gfedc
gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
RecordsAdult Thoracic - Heart/Lung Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Physician Name:
Physician NPI#:
Surgeon Name:
Surgeon NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Patient on Life Support: YES NOnmlkj nmlkj
Extra Corporeal Membrane Oxygenationgfedc
Intra Aortic Balloon Pumpgfedc
Prostacyclin Infusiongfedc
Prostacyclin Inhalationgfedc
Inhaled NOgfedc
Ventilatorgfedc
Other Mechanismgfedc
Specify:
Patient on Ventricular Assist Device
NONEnmlkj
LVADnmlkj
RVADnmlkj
TAHnmlkj
LVAD+RVADnmlkj
Life Support: VAD Brand1
Specify:
Life Support: VAD Brand2
Specify:
Functional Status:
Physical Capacity:
No Limitationsnmlkj
Limited Mobilitynmlkj
Wheelchair bound or more limitednmlkj
Not Applicable (< 1 year old or hospitalized)nmlkj
Unknownnmlkj
Working for income: YES NO UNKnmlkj nmlkj nmlkj
If No, Not Working Due To:
If Yes:
Working Full Timenmlkj
Working Part Time due to Demands of Treatmentnmlkj
Working Part Time due to Disabilitynmlkj
Working Part Time due to Insurance Conflictnmlkj
Working Part Time due to Inability to Find Full Time Worknmlkj
Working Part Time due to Patient Choicenmlkj
Working Part Time Reason Unknownnmlkj
Working, Part Time vs. Full Time Unknownnmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Viral Detection:
Positivenmlkj
HIV Serostatus:
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Most Recent Hemodynamics: Inotropes/Vasodilators:
PA (sys)mm/Hg:ST=
YES NOnmlkj nmlkj
PA(dia) mm/Hg:ST=
YES NOnmlkj nmlkj
PA(mean) mm/Hg:ST=
YES NOnmlkj nmlkj
PCW(mean) mm/Hg:ST=
YES NOnmlkj nmlkj
CO L/min:ST=
YES NOnmlkj nmlkj
Most Recent Serum Creatinine: mg/dl ST=
Most Recent Total Bilirubin: mg/dl ST=
Oxygen Requirement at Rest: L/min ST=
Chronic Steroid Use: YES NO UNKnmlkj nmlkj nmlkj
Pulmonary Status (Give most recent value):
FVC: %predicted: ST=
FeV1: %predicted: ST=
pCO2: mm/Hg: ST=
Events occurring between listing and transplant:
Transfusions: YES NO UNKnmlkj nmlkj nmlkj
Infection Requiring IV Therapy within 2 wks prior toTx: YES NO UNKnmlkj nmlkj nmlkj
Cerebrovascular Event: YES NO UNKnmlkj nmlkj nmlkj
Dialysis: YES NO UNKnmlkj nmlkj nmlkj
Implantable Defibrillator: YES NO UNKnmlkj nmlkj nmlkj
Prior Cardiac Surgery (non-transplant): YES NO UNKnmlkj nmlkj nmlkj
If yes, check all that apply:
CABGgfedc
Valve Replacement/Repairgfedc
Congenitalgfedc
Left Ventricular Remodelinggfedc
Other, specifygfedc
Specify:
Prior Lung Surgery (non-transplant): YES NO UNKnmlkj nmlkj nmlkj
If yes, check all that apply:
Pneumoreductiongfedc
Pneumothorax Surgery-Nodulegfedc
Pneumothorax Decorticationgfedc
Lobectomygfedc
Pneumonectomygfedc
Left Thoracotomygfedc
Right Thoracotomygfedc
Other, specifygfedc
Specify:
Episode of Ventilatory Support: YES NO UNKnmlkj nmlkj nmlkj
If yes, indicate most recent timeframe:
At time of transplantnmlkj
Within 3 months of transplantnmlkj
>3 months prior to transplantnmlkj
Tracheostomy: YES NO UNKnmlkj nmlkj nmlkj
Previous Pregnancies:
NO PREVIOUS PREGNANCYnmlkj
1 PREVIOUS PREGNANCYnmlkj
2 PREVIOUS PREGNANCIESnmlkj
3 PREVIOUS PREGNANCIESnmlkj
4 PREVIOUS PREGNANCIESnmlkj
5 PREVIOUS PREGNANCIESnmlkj
MORE THAN 5 PREVIOUS PREGNANCIESnmlkj
NOT APPLICABLE: < 10 years oldnmlkj
UNKNOWNnmlkj
(which may or may not have resulted in a live birth)
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Heartnmlkj
Procedure Type: Heart Lungnmlkj
Was this a retransplant due to failure of a previousthoracic graft: YES NOnmlkj nmlkj
Total Organ Ischemia Time (include cold, warm and anastomotic time):
Heart, Heart-Lung: min ST=
Incidental Tumor found at time of Transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, specify tumor type:
Adenomanmlkj
Carcinomanmlkj
Carcinoidnmlkj
Lymphomanmlkj
Harmartomanmlkj
Other Primary Lung Tumor, Specifynmlkj
Specify:
Clinical Information : POST TRANSPLANT
Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Date of Graft Failure:
Primary Cause of Graft Failure:
Primary Non-Functionnmlkj
Acute Rejectionnmlkj
Chronic Rejection/Atherosclerosisnmlkj
Other, Specifynmlkj
Specify:
Events Prior to Discharge:
Any Drug Treated Infection: YES NO UNKnmlkj nmlkj nmlkj
Stroke: YES NO UNKnmlkj nmlkj nmlkj
Dialysis: YES NO UNKnmlkj nmlkj nmlkj
Cardiac Re-Operation: YES NO UNKnmlkj nmlkj nmlkj
Other Surgical Procedures: YES NO UNKnmlkj nmlkj nmlkj
Time on inotropes other than Isoproterenol (Isuprel): days ST=
Ventilator Support:
Nonmlkj
Ventilator support for <= 48 hoursnmlkj
Ventilator support for >48 hours but < 5 daysnmlkj
Ventilator support >= 5 daysnmlkj
Ventilator support, duration unknownnmlkj
Unknown Statusnmlkj
Reintubated: YES NO UNKnmlkj nmlkj nmlkj
Permanent Pacemaker: YES NO UNKnmlkj nmlkj nmlkj
Chest drain >2 weeks: YES NO UNKnmlkj nmlkj nmlkj
Airway Dehiscence: YES NO UNKnmlkj nmlkj nmlkj
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
UNOS View Only
Comments:
RecordsPediatric Kidney Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Surgeon Name:
NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Functional Status:
Cognitive Development:
Definite Cognitive delay/impairmentnmlkj
Probable Cognitive delay/impairmentnmlkj
Questionable Cognitive delay/impairmentnmlkj
No Cognitive delay/impairmentnmlkj
Not Assessednmlkj
Motor Development:
Definite Motor delay/impairmentnmlkj
Probable Motor delay/impairmentnmlkj
Questionable Motor delay/impairmentnmlkj
No Motor delay/impairmentnmlkj
Not Assessednmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Unable to participate regularly in academics due to dialysisnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Pretransplant Dialysis: YES NO UNKnmlkj nmlkj nmlkj
If Yes, Date of Most Recent Initiation of ChronicMaintenance Dialysis: ST=
Serum Creatinine at Time of Tx: mg/dl ST=
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Positivenmlkj
EBV Serostatus:
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Was preimplantation kidney biopsy performed at thetransplant center: YES NOnmlkj nmlkj
Did patient receive any pretransplant bloodtransfusions: YES NO UNKnmlkj nmlkj nmlkj
Any tolerance induction technique used: YES NO UNKnmlkj nmlkj nmlkj
Previous Pregnancies:
NO PREVIOUS PREGNANCYnmlkj
1 PREVIOUS PREGNANCYnmlkj
2 PREVIOUS PREGNANCIESnmlkj
3 PREVIOUS PREGNANCIESnmlkj
4 PREVIOUS PREGNANCIESnmlkj
5 PREVIOUS PREGNANCIESnmlkj
MORE THAN 5 PREVIOUS PREGNANCIESnmlkj
NOT APPLICABLE: < 10 years oldnmlkj
UNKNOWNnmlkj
(which may or may not have resulted in a live birth)
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Other, specifygfedc
Specify:
Bone Disease:
Fracture in the past year (or since last follow-up): YES NO UNKnmlkj nmlkj nmlkj
Specify Location and number of fractures:
Spine-compression fracture:gfedc # of fractures:
Extremity:gfedc # of fractures:
Other:gfedc # of fractures:
AVN (avascular necrosis): YES NO UNKnmlkj nmlkj nmlkj
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Type:
Kidney Preservation Information:
Total Cold ischemia Time Right KI(OR EN-BLOC): (ifpumped, include pump time):
hrs ST=
Total Warm Ischemia Time Right KI (OR EN-BLOC):(Include Anastomotic time):
min ST=
Total Cold ischemia Time Left KI (if pumped, includepump time):
hrs ST=
Total Warm ischemia Time Left KI (include Anastomotictime):
min ST=
Kidney(s) received on:
Icenmlkj
Pumpnmlkj
N/Anmlkj
Received on ice:Stayed on icenmlkj
Put on pumpnmlkj
Received on pump:Stayed on pumpnmlkj
Put on icenmlkj
If put on pump or stayed on pump:
Final resistance at transplant: ST=
Final flow rate at transplant: ST=
Incidental Tumor found at time of Transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, specify tumor type:
Oncocytomanmlkj
Renal Cell Carcinomanmlkj
Carcinoidnmlkj
Adenomanmlkj
Transitional Cell Carcinomanmlkj
Other Primary Kidney Tumor, Specify.nmlkj
Specify:
Clinical Information : POST TRANSPLANT
Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Resumed Maintenance Dialysis: YES NOnmlkj nmlkj
Date Maintenance Dialysis Resumed:
Select a Dialysis Provider:
Provider #:
Provider Name:
Date of Graft Failure:
Primary Cause of Graft Failure:
HYPERACUTE REJECTIONnmlkj
ACUTE REJECTIONnmlkj
PRIMARY FAILUREnmlkj
GRAFT THROMBOSISnmlkj
INFECTIONnmlkj
SURGICAL COMPLICATIONSnmlkj
UROLOGICAL COMPLICATIONSnmlkj
RECURRENT DISEASEnmlkj
OTHER SPECIFY CAUSEnmlkj
Specify:
Contributory causes of graft failure:
Acute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Graft Thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Infection: YES NO UNKnmlkj nmlkj nmlkj
Surgical Complications: YES NO UNKnmlkj nmlkj nmlkj
Urological Complications: YES NO UNKnmlkj nmlkj nmlkj
Recurrent Disease: YES NO UNKnmlkj nmlkj nmlkj
Other, Specify:
Most Recent Serum Creatinine Prior to Discharge: mg/dl ST=
Kidney Produced > 40ml of Urine in First 24 Hours: YES NOnmlkj nmlkj
Patient Need Dialysis within First Week: YES NOnmlkj nmlkj
Creatinine decline by 25% or more in first 24 hours on 2
separate samples:YES NOnmlkj nmlkj
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Is growth hormone therapy used between listing andtransplant: YES NO UNKnmlkj nmlkj nmlkj
Date of Measurement:
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
UNOS View Only
Comments:
RecordsPediatric Kidney-Pancreas Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Surgeon Name:
NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Kidney Primary Diagnosis:
Specify:
Pancreas Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Retransplanted organ: Kidney Pancreas Kidney/Pancreasnmlkj nmlkj nmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Functional Status:
Cognitive Development:
Definite Cognitive delay/impairmentnmlkj
Probable Cognitive delay/impairmentnmlkj
Questionable Cognitive delay/impairmentnmlkj
No Cognitive delay/impairmentnmlkj
Not Assessednmlkj
Motor Development:
Definite Motor delay/impairmentnmlkj
Probable Motor delay/impairmentnmlkj
Questionable Motor delay/impairmentnmlkj
No Motor delay/impairmentnmlkj
Not Assessednmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Unable to participate regularly in academics due to dialysisnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Kidney Source of Payment:
Primary:
Specify:
Secondary:
Pancreas Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Date of Measurement:
Height: ft. in. cm ST=
Weight: kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Pretransplant Dialysis: YES NO UNKnmlkj nmlkj nmlkj
If Yes, Date of Most Recent Initiation of ChronicMaintenance Dialysis: ST=
Average Daily Insulin Units: ST=
Serum Creatinine at Time of Tx: mg/dl ST=
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Was preimplantation kidney biopsy performed at thetransplant center: YES NOnmlkj nmlkj
Did patient receive any pretransplant bloodtranfusions: YES NO UNKnmlkj nmlkj nmlkj
Any tolerance induction technique used: YES NO UNKnmlkj nmlkj nmlkj
Previous Pregnancies:
NO PREVIOUS PREGNANCYnmlkj
1 PREVIOUS PREGNANCYnmlkj
2 PREVIOUS PREGNANCIESnmlkj
3 PREVIOUS PREGNANCIESnmlkj
4 PREVIOUS PREGNANCIESnmlkj
5 PREVIOUS PREGNANCIESnmlkj
MORE THAN 5 PREVIOUS PREGNANCIESnmlkj
NOT APPLICABLE: < 10 years oldnmlkj
UNKNOWNnmlkj
(which may or may not have resulted in a live birth)
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
Skin Melanomagfedc
If yes, specify type:
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Other, specifygfedc
Specify:
Bone Disease:
Fracture in the past year (or since last follow-up): YES NO UNKnmlkj nmlkj nmlkj
Specify Location and number of fractures:
Spine-compression fracture:gfedc # of fractures:
Extremity:gfedc # of fractures:
Other:gfedc # of fractures:
AVN (avascular necrosis): YES NO UNKnmlkj nmlkj nmlkj
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Type:
Surgical Information:
Was the Pancreas revascularized before or after otherorgans:
Beforenmlkj
Simultaneousnmlkj
Afternmlkj
Not Applicablenmlkj
Surgical Incision:
Iliac Fossa PA left/KI rightnmlkj
Iliac Fossa PA right/KI leftnmlkj
Leftnmlkj
Midlinenmlkj
Rightnmlkj
Graft Placement:INTRA-PERITONEALnmlkj
RETRO-PERITONEALnmlkj
PARTIAL INTRA/RETRO-PERITONEALnmlkj
Operative Technique:
Simultaneous Kidney-Pancreasnmlkj
Clusternmlkj
Multi-Organ Non-Clusternmlkj
Duct Management:
ENTERIC W/ROUX-EN-Ynmlkj
ENTERIC W/O ROUX-EN-Ynmlkj
CYSTOSTOMYnmlkj
DUCT INJECTION IMMEDIATEnmlkj
DUCT INJECTION DELAYEDnmlkj
OTHER SPECIFYnmlkj
Specify:
Venous Vascular Management:
SYSTEMIC SYSTEM (ILIAC:CAVA)nmlkj
PORTAL SYSTEM (PORTAL OR TRIBUTARIES)nmlkj
NA/Multi-organ clusternmlkj
Arterial Reconstruction:
CELIAC WITH PANCREASnmlkj
Y-GRAFT TO SPA & SMAnmlkj
SPA TO SMA DIRECTnmlkj
SPA TO SMA WITH INTERPOSITIONnmlkj
SPA ALONEnmlkj
OTHER SPECIFYnmlkj
Specify:
Venous Extension Graft: YES NOnmlkj nmlkj
Kidney and Pancreas Preservation Information:
Total Cold ischemia Time Right KI(OR EN-BLOC): (ifpumped, include pump time):
hrs ST=
Total Warm Ischemia Time Right KI (OR EN-BLOC):(Include Anastomotic time):
min ST=
Total Cold Ischemia Time Left KI (If pumped, includepump time):
hrs ST=
Total Warm ischemia Time Left KI (Include Anastomotictime):
min ST=
Total Pancreas Preservation Time (include Cold, Warm,Anastomotic time):
hrs ST=
Kidney(s) received on:
Icenmlkj
Pumpnmlkj
N/Anmlkj
Received on ice:Stayed on icenmlkj
Put on pumpnmlkj
Received on pump:Stayed on pumpnmlkj
Put on icenmlkj
If put on pump or stayed on pump:
Final resistance at transplant: ST=
Final flow rate at transplant: ST=
Incidental Tumor found at time of Transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, specify tumor type:
Oncocytomanmlkj
Renal Cell Carcinomanmlkj
Carcinoidnmlkj
Adenomanmlkj
Transitional Cell Carcinomanmlkj
Other Primary Kidney Tumor, Specify.nmlkj
Specify:
Clinical Information : POST TRANSPLANT
Kidney Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Resumed Maintenance Dialysis: YES NOnmlkj nmlkj
Date Maintenance Dialysis Resumed:
Select a Dialysis Provider:
Provider #:
Provider Name:
Kidney Date of Graft Failure:
Kidney Primary Cause of Graft Failure:
HYPERACUTE REJECTIONnmlkj
ACUTE REJECTIONnmlkj
PRIMARY FAILUREnmlkj
GRAFT THROMBOSISnmlkj
INFECTIONnmlkj
SURGICAL COMPLICATIONSnmlkj
UROLOGICAL COMPLICATIONSnmlkj
RECURRENT DISEASEnmlkj
OTHER SPECIFY CAUSEnmlkj
Specify:
Contributory causes of graft failure:
Kidney Acute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Kidney Graft Thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Kidney Infection: YES NO UNKnmlkj nmlkj nmlkj
Surgical Complications: YES NO UNKnmlkj nmlkj nmlkj
Urological Complications: YES NO UNKnmlkj nmlkj nmlkj
Recurrent Disease: YES NO UNKnmlkj nmlkj nmlkj
Other, Specify:
Did patient have any acute kidney rejection episodesbetween transplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Is growth hormone therapy used between listing andtransplant: YES NO UNKnmlkj nmlkj nmlkj
Most Recent Serum Creatinine Prior to Discharge: mg/dl ST=
Kidney Produced > 40ml of Urine in First 24 Hours: YES NOnmlkj nmlkj
Patient Need Dialysis within First Week: YES NOnmlkj nmlkj
Creatinine Decline by 25% or More in First 24 Hours on 2separate samples: YES NOnmlkj nmlkj
Pancreas Graft Status: Functioning Partial Function Failednmlkj nmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Method of blood sugar control: (check all that apply)
Insulingfedc
Oral medicationgfedc
Dietgfedc
No Treatmentgfedc
Date Insulin/Medication Resumed:
Date of Graft Failure Pancreas:
Pancreas Graft Removed: YES NO UNKnmlkj nmlkj nmlkj
If Yes, Date Pancreas Graft Removed:
Pancreas Primary Cause of Graft Failure:
Pancreas Primary Cause of Graft Failure/Specify:
Contributory causes of graft failure:
Pancreas Graft/Vascular Thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Pancreas Infection: YES NO UNKnmlkj nmlkj nmlkj
Bleeding: YES NO UNKnmlkj nmlkj nmlkj
Anastomotic Leak: YES NO UNKnmlkj nmlkj nmlkj
Hyperacute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Pancreas Acute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Biopsy Proven Isletitis: YES NO UNKnmlkj nmlkj nmlkj
Pancreatitis: YES NO UNKnmlkj nmlkj nmlkj
Other, Specify:
Did patient have any acute pancreas rejection episodesbetween transplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Pancreas Transplant Complications:
(Not leading to graft failure.)
Pancreatitis: YES NO UNKnmlkj nmlkj nmlkj
Anastomotic Leak: YES NO UNKnmlkj nmlkj nmlkj
Abcess or Local Infection: YES NO UNKnmlkj nmlkj nmlkj
Other:
Weight Post Transplant: lbs. kg ST=
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
Acyclovir (Zovirax)gfedc
If Yes, check all that apply:
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc
gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
UNOS View Only
Comments:
RecordsPediatric Pancreas Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Surgeon Name:
NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Functional Status:
Cognitive Development:
Definite Cognitive delay/impairmentnmlkj
Probable Cognitive delay/impairmentnmlkj
Questionable Cognitive delay/impairmentnmlkj
No Cognitive delay/impairmentnmlkj
Not Assessednmlkj
Motor Development:
Definite Motor delay/impairmentnmlkj
Probable Motor delay/impairmentnmlkj
Questionable Motor delay/impairmentnmlkj
No Motor delay/impairmentnmlkj
Not Assessednmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Date of Measurement:
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Pretransplant Dialysis: YES NO UNKnmlkj nmlkj nmlkj
If Yes, Date of Most Recent Initiation of ChronicMaintenance Dialysis: ST=
Average Daily Insulin Units: ST=
Serum Creatinine at Time of Tx: mg/dl ST=
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Positivenmlkj
Negativenmlkj
HCV Serostatus:Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Type:
Surgical Information:
If a simultaneous Tx with another organ, was thePancreas revascularized before or after other organs:
Beforenmlkj
Simultaneousnmlkj
Afternmlkj
Not Applicablenmlkj
Surgical Incision:
Leftnmlkj
Midlinenmlkj
Othernmlkj
Rightnmlkj
Graft Placement:
INTRA-PERITONEALnmlkj
RETRO-PERITONEALnmlkj
PARTIAL INTRA/RETRO-PERITONEALnmlkj
Operative Technique:
PANCREAS ALONEnmlkj
CLUSTERnmlkj
MULTI-ORGAN NON-CLUSTERnmlkj
PANCREAS AFTER KIDNEYnmlkj
PANCREAS WITH KIDNEY DIFFERENT DONORnmlkj
Duct Management:
ENTERIC W/ROUX-EN-Ynmlkj
ENTERIC W/O ROUX-EN-Ynmlkj
CYSTOSTOMYnmlkj
DUCT INJECTION IMMEDIATEnmlkj
DUCT INJECTION DELAYEDnmlkj
OTHER SPECIFYnmlkj
Specify:
Venous Vascular Management:
SYSTEMIC SYSTEM (ILIAC:CAVA)nmlkj
PORTAL SYSTEM (PORTAL OR TRIBUTARIES)nmlkj
NA/Multi-organ clusternmlkj
Arterial Reconstruction:
CELIAC WITH PANCREASnmlkj
Y-GRAFT TO SPA & SMAnmlkj
SPA TO SMA DIRECTnmlkj
SPA TO SMA WITH INTERPOSITIONnmlkj
SPA ALONEnmlkj
OTHER SPECIFYnmlkj
Specify:
Venous Extension Graft: YES NOnmlkj nmlkj
Preservation Information:
Total Pancreas Preservation Time (include Cold, Warm,Anastomotic time):
hrs ST=
Clinical Information : POST TRANSPLANT
Pancreas Graft Status: Functioning Partial Function Failednmlkj nmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Insulingfedc
Method of blood sugar control: (check all that apply)
Oral medicationgfedc
Dietgfedc
No Treatmentgfedc
Date insulin/medication first resumed:
Date of Graft Failure:
Pancreas Graft Removed: YES NO UNKnmlkj nmlkj nmlkj
Date Pancreas Graft Removed:
Pancreas Primary Cause of Graft Failure:
Specify:
Contributory causes of graft failure:
Pancreas Graft/Vascular Thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Pancreas Infection: YES NO UNKnmlkj nmlkj nmlkj
Bleeding: YES NO UNKnmlkj nmlkj nmlkj
Anastomotic Leak: YES NO UNKnmlkj nmlkj nmlkj
Hyperacute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Pancreas Acute Rejection: YES NO UNKnmlkj nmlkj nmlkj
Biopsy Proven Isletitis: YES NO UNKnmlkj nmlkj nmlkj
Pancreatitis: YES NO UNKnmlkj nmlkj nmlkj
Other, Specify:
Pancreas Transplant Complications:
(Not leading to graft failure.)
Pancreatitis: YES NO UNKnmlkj nmlkj nmlkj
Anastomotic Leak: YES NO UNKnmlkj nmlkj nmlkj
Abcess or Local Infection: YES NO UNKnmlkj nmlkj nmlkj
Pancreas Transplant Complications: Other
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.
For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
UNOS View Only
Comments:
RecordsPediatric Liver Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Surgeon Name:
NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Patient on Life Support: YES NOnmlkj nmlkj
Ventilatorgfedc
Artificial Livergfedc
Other Mechanism, Specifygfedc
Specify:
Functional Status:
Cognitive Development:
Definite Cognitive delay/impairmentnmlkj
Probable Cognitive delay/impairmentnmlkj
Questionable Cognitive delay/impairmentnmlkj
No Cognitive delay/impairmentnmlkj
Not Assessednmlkj
Motor Development:
Definite Motor delay/impairmentnmlkj
Probable Motor delay/impairmentnmlkj
Questionable Motor delay/impairmentnmlkj
No Motor delay/impairmentnmlkj
Not Assessednmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Date of Measurement:
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Any tolerance induction technique used: YES NO UNKnmlkj nmlkj nmlkj
Pretransplant Lab Date:
SGPT/ALT: U/L ST=
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Hepatoblastomagfedc
Hepatocellular Carcinomagfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Surgical Procedure:ORTHOTOPICnmlkj
HETEROTOPICnmlkj
Procedure Type:
Whole Livernmlkj
Partial Liver, remainder not Tx or Living Transplantnmlkj
Split Livernmlkj
Whole Liver with Pancreas (Technical Reasons)nmlkj
Partial Liver with Pancreas (Technical Reasons)nmlkj
Split Liver with Pancreas (Technical Reasons)nmlkj
Split Type:
Preservation Information:
Warm Ischemia Time (include anastomotic time): min ST=
Total Cold Ischemia Time (if pumped, include pumptime):
hrs ST=
Risk Factors:
Did Patient receive 5 or more units of packed red bloodcells within 48 hours prior to transplantation due tospontaneous portal hypertensive bleeding:
YES NO UNKnmlkj nmlkj nmlkj
Spontaneous Bacterial Peritonitis: YES NO UNKnmlkj nmlkj nmlkj
Previous Abdominal Surgery: YES NO UNKnmlkj nmlkj nmlkj
Portal Vein Thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Transjugular Intrahepatic Portacaval Stint Shunt: YES NO UNKnmlkj nmlkj nmlkj
Incidental Tumor found at time of Transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, specify tumor type:
Hepatocellular Adenomanmlkj
Hemangiomanmlkj
Hemangioendotheliomanmlkj
Angiomyolipomanmlkj
Bile Duct Cystadenocarcinomanmlkj
Cholangiocarcinomanmlkj
Hepatocellular Carcinomanmlkj
Hepatoblastomanmlkj
Angiosarcomanmlkj
Other Primary Liver Tumor, Specifynmlkj
Specify:
Clinical Information : POST TRANSPLANT
Pathology Conf. Liver Diag. of Hospital Discharge:
Specify:
Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Date of Graft Failure:
Causes of graft failure:
Primary Graft Failure YES NO UNKnmlkj nmlkj nmlkj
Vascular Thrombosis YES NO UNKnmlkj nmlkj nmlkj
Hepatic arterial thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Hepatic outflow obstruction: YES NO UNKnmlkj nmlkj nmlkj
Portal vein thrombosis: YES NO UNKnmlkj nmlkj nmlkj
Biliary Tract Complication YES NO UNKnmlkj nmlkj nmlkj
Hepatitis: DeNovo YES NO UNKnmlkj nmlkj nmlkj
Hepatitis: Recurrent YES NO UNKnmlkj nmlkj nmlkj
Recurrent Disease (non-Hepatitis) YES NO UNKnmlkj nmlkj nmlkj
Acute Rejection YES NO UNKnmlkj nmlkj nmlkj
Infection YES NO UNKnmlkj nmlkj nmlkj
Other, Specify:
Discharge Lab Date:
Total Bilirubin: mg/dl ST=
SGPT/ALT: U/L ST=
Serum Albumin: g/dl ST=
Serum Creatinine: mg/dl ST=
INR: ST=
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
UNOS View Only
Comments:
RecordsPediatric Intestine Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Surgeon Name:
NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Secondary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Patient on Life Support: YES NOnmlkj nmlkj
Ventilatorgfedc
Artificial Livergfedc
Other Mechanism, Specifygfedc
Specify:
Functional Status:
Cognitive Development:
Definite Cognitive delay/impairmentnmlkj
Probable Cognitive delay/impairmentnmlkj
Questionable Cognitive delay/impairmentnmlkj
No Cognitive delay/impairmentnmlkj
Not Assessednmlkj
Motor Development:
Definite Motor delay/impairmentnmlkj
Probable Motor delay/impairmentnmlkj
Questionable Motor delay/impairmentnmlkj
No Motor delay/impairmentnmlkj
Not Assessednmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Date of Measurement:
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Positivenmlkj
HBV Surface Antigen:
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Total Bilirubin: mg/dl ST=
Serum Albumin: g/dl ST=
Serum Creatinine: mg/dl ST=
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Hepatoblastomagfedc
Hepatocellular Carcinomagfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Information:
Intestine Venous Drainage: Portal Systemicnmlkj nmlkj
Native Viscera Venous Drainage: Portal Systemicnmlkj nmlkj
Procedure Type:
Whole Intestinenmlkj
Intestine Segmentnmlkj
Whole Intestine with Pancreas (Technical Reasons)nmlkj
Intestine Segment with Pancreas (Technical Reasons)nmlkj
Organ Type: Stomachgfedc
Small Intestinegfedc
Duodenumgfedc
Large Intestinegfedc
Preservation Information:
Total Ischemic Time (include cold, warm andanastomotic time):
hrs ST=
Risk Factors:
Recent Septicemia: YES NO UNKnmlkj nmlkj nmlkj
Exhausted Vascular Access: YES NO UNKnmlkj nmlkj nmlkj
Liver Dysfunction: YES NO UNKnmlkj nmlkj nmlkj
Previous Abdominal Surgery: YES NO UNKnmlkj nmlkj nmlkj
Number Previous Abdominal Surgeries: ST=
Dilated/Non-Functional Bowel Segments: YES NO UNKnmlkj nmlkj nmlkj
Other:
Clinical Information : POST TRANSPLANT
Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
TPN Dependent: YES NOnmlkj nmlkj
IV Dependent: YES NOnmlkj nmlkj
Oral Feeding: YES NOnmlkj nmlkj
Tube Feed: YES NOnmlkj nmlkj
Date of Graft Failure:
Primary Cause of Graft Failure:
RECURRENT TUMORnmlkj
ACUTE REJECTIONnmlkj
CHRONIC REJECTIONnmlkj
TECHNICAL PROBLEMSnmlkj
INFECTIONnmlkj
LYMPHOPROLIFERATIVE DISEASEnmlkj
GVHD (Graft Versus Host Disease)nmlkj
Ischemia/NEC (Necrotizing Enterocolitis) Like Syndromenmlkj
OTHER SPECIFYnmlkj
Specify:
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
UNOS View Only
Comments:
RecordsPediatric Thoracic - Lung Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Physician Name:
Physician NPI#:
Surgeon Name:
Surgeon NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Patient on Life Support: YES NOnmlkj nmlkj
Extra Corporeal Membrane Oxygenationgfedc
Intra Aortic Balloon Pumpgfedc
Prostacyclin Infusiongfedc
Prostacyclin Inhalationgfedc
Intravenous Inotropesgfedc
Inhaled NOgfedc
Ventilatorgfedc
Other Mechanismgfedc
Specify:
Functional Status:
Cognitive Development:
Definite Cognitive delay/impairmentnmlkj
Probable Cognitive delay/impairmentnmlkj
Questionable Cognitive delay/impairmentnmlkj
No Cognitive delay/impairmentnmlkj
Not Assessednmlkj
Motor Development:
Definite Motor delay/impairmentnmlkj
Probable Motor delay/impairmentnmlkj
Questionable Motor delay/impairmentnmlkj
No Motor delay/impairmentnmlkj
Not Assessednmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Date of Measurement:
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Positivenmlkj
HBV Core Antibody:
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Most Recent Hemodynamics: Inotropes/Vasodilators:
PA (sys)mm/Hg:ST=
YES NOnmlkj nmlkj
PA(dia) mm/Hg:ST=
YES NOnmlkj nmlkj
PA(mean) mm/Hg:ST=
YES NOnmlkj nmlkj
PCW(mean) mm/Hg:ST=
YES NOnmlkj nmlkj
CO L/min:ST=
YES NOnmlkj nmlkj
Most Recent Serum Creatinine: mg/dl ST=
Most Recent Total Bilirubin: mg/dl ST=
Oxygen Requirement at Rest: L/min ST=
Chronic Steroid Use: YES NO UNKnmlkj nmlkj nmlkj
Pulmonary Status (Give most recent value):
FVC: %predicted: ST=
FeV1: %predicted: ST=
pCO2: mm/Hg: ST=
Events occurring between listing and transplant:
Transfusions: YES NO UNKnmlkj nmlkj nmlkj
Pulmonary Embolism: YES NO UNKnmlkj nmlkj nmlkj
Infection Requiring IV Therapy within 2 wks prior toTx: YES NO UNKnmlkj nmlkj nmlkj
Cerebrovascular Event: YES NO UNKnmlkj nmlkj nmlkj
Dialysis: YES NO UNKnmlkj nmlkj nmlkj
Implantable Defibrillator: YES NO UNKnmlkj nmlkj nmlkj
Episode of Ventilatory Support: YES NO UNKnmlkj nmlkj nmlkj
If yes, indicate most recent timeframe:
At time of transplantnmlkj
Within 3 months of transplantnmlkj
>3 months prior to transplantnmlkj
Tracheostomy: YES NO UNKnmlkj nmlkj nmlkj
Prior Thoracic Surgery other than prior transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, number of prior sternotomies:
Unknown if there were prior sternotomiesnmlkj
0nmlkj
1nmlkj
2nmlkj
3nmlkj
4nmlkj
5+nmlkj
Unknown number of prior sternotomiesnmlkj
If yes, number of prior thoracotomies:
Unknown if there were prior thoracotomiesnmlkj
0nmlkj
1nmlkj
2nmlkj
3nmlkj
4nmlkj
5+nmlkj
Unknown number of prior thoracotomiesnmlkj
Prior congenital cardiac surgery: YES NO UNKnmlkj nmlkj nmlkj
If yes, palliative surgery: YES NO UNKnmlkj nmlkj nmlkj
If yes, corrective surgery: YES NO UNKnmlkj nmlkj nmlkj
If yes, single ventricular physiology: YES NO UNKnmlkj nmlkj nmlkj
Previous Pregnancies:
NO PREVIOUS PREGNANCYnmlkj
1 PREVIOUS PREGNANCYnmlkj
2 PREVIOUS PREGNANCIESnmlkj
3 PREVIOUS PREGNANCIESnmlkj
4 PREVIOUS PREGNANCIESnmlkj
5 PREVIOUS PREGNANCIESnmlkj
MORE THAN 5 PREVIOUS PREGNANCIESnmlkj
NOT APPLICABLE: < 10 years oldnmlkj
UNKNOWNnmlkj
(which may or may not have resulted in a live birth)
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Type:
SINGLE LEFT LUNGnmlkj
SINGLE RIGHT LUNGnmlkj
BILATERAL SEQUENTIAL LUNGnmlkj
EN-BLOC DOUBLE LUNGnmlkj
LOBE, RIGHTnmlkj
LOBE, LEFTnmlkj
Was this a retransplant due to failure of a previous
thoracic graft:YES NOnmlkj nmlkj
Total Organ Ischemia Time (include cold, warm and anastomotic time):
Left Lung: min ST=
Right Lung (OR EN-BLOC): min ST=
Incidental Tumor found at time of Transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, specify tumor type:
Adenomanmlkj
Carcinomanmlkj
Carcinoidnmlkj
Lymphomanmlkj
Harmartomanmlkj
Other Primary Lung Tumor, Specifynmlkj
Specify:
Clinical Information : POST TRANSPLANT
Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Date of Graft Failure:
Primary Cause of Graft Failure:
Primary Non-Functionnmlkj
Acute Rejectionnmlkj
Chronic Rejection/Atherosclerosisnmlkj
Other, Specifynmlkj
Specify:
Events Prior to Discharge:
Any Drug Treated Infection: YES NO UNKnmlkj nmlkj nmlkj
Stroke: YES NO UNKnmlkj nmlkj nmlkj
Dialysis: YES NO UNKnmlkj nmlkj nmlkj
Cardiac Re-Operation: YES NO UNKnmlkj nmlkj nmlkj
Other Surgical Procedures: YES NO UNKnmlkj nmlkj nmlkj
Ventilator Support:
Nonmlkj
Ventilator support for <= 48 hoursnmlkj
Ventilator support for >48 hours but < 5 daysnmlkj
Ventilator support >= 5 daysnmlkj
Ventilator support, duration unknownnmlkj
Unknown Statusnmlkj
Reintubated: YES NO UNKnmlkj nmlkj nmlkj
Permanent Pacemaker: YES NO UNKnmlkj nmlkj nmlkj
Chest drain >2 weeks: YES NO UNKnmlkj nmlkj nmlkj
Airway Dehiscence: YES NO UNKnmlkj nmlkj nmlkj
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
RecordsPediatric Thoracic - Heart/Lung Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 03/31/2015
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI®
application. Currently in the worksheet, a red asterisk is
displayed by fields that are required, independent of what other data may be provided. Based on data provided through the online TIEDI®
application, additional fields that are
dependent on responses provided in these required fields may become required as well. However, since those fields are not required in every case, they are not marked with
a red asterisk.
Recipient Information
Name: DOB:
SSN: Gender:
HIC: Tx Date:
State of Permanent Residence:
Permanent Zip: -
Provider Information
Recipient Center:
Physician Name:
Physician NPI#:
Surgeon Name:
Surgeon NPI#:
Donor Information
UNOS Donor ID #:
Donor Type:
Patient Status
Primary Diagnosis:
Specify:
Date: Last Seen, Retransplanted or Death
Patient Status:
LIVINGnmlkj
DEADnmlkj
RETRANSPLANTEDnmlkj
Primary Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Contributory Cause of Death:
Specify:
Transplant Hospitalization:
Date of Admission to Tx Center:
Date of Discharge from Tx Center:
Was patient hospitalized during the last 90 days prior tothe transplant admission: YES NO UNKnmlkj nmlkj nmlkj
Medical Condition at time of transplant:
IN INTENSIVE CARE UNITnmlkj
HOSPITALIZED NOT IN ICUnmlkj
NOT HOSPITALIZEDnmlkj
Patient on Life Support: YES NOnmlkj nmlkj
Extra Corporeal Membrane Oxygenationgfedc
Intra Aortic Balloon Pumpgfedc
Prostacyclin Infusiongfedc
Prostacyclin Inhalationgfedc
Intravenous Inotropesgfedc
Inhaled NOgfedc
Ventilatorgfedc
Other Mechanismgfedc
Specify:
Patient on Ventricular Assist Device
NONEnmlkj
LVADnmlkj
RVADnmlkj
TAHnmlkj
LVAD+RVADnmlkj
Life Support: VAD Brand1
Specify:
Life Support: VAD Brand2
Specify:
Functional Status:
Cognitive Development:
Definite Cognitive delay/impairmentnmlkj
Probable Cognitive delay/impairmentnmlkj
Questionable Cognitive delay/impairmentnmlkj
No Cognitive delay/impairmentnmlkj
Not Assessednmlkj
Motor Development:
Definite Motor delay/impairmentnmlkj
Probable Motor delay/impairmentnmlkj
Questionable Motor delay/impairmentnmlkj
No Motor delay/impairmentnmlkj
Not Assessednmlkj
Academic Progress:
Within One Grade Level of Peersnmlkj
Delayed Grade Levelnmlkj
Special Educationnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Academic Activity Level:
Full academic loadnmlkj
Reduced academic loadnmlkj
Unable to participate in academics due to disease or conditionnmlkj
Not Applicable < 5 years old/ High School graduate or GEDnmlkj
Status Unknownnmlkj
Source of Payment:
Primary:
Specify:
Secondary:
Clinical Information : PRETRANSPLANT
Date of Measurement:
Height: ft. in. cm ST=
Weight: lbs kg ST=
BMI: kg/m2
Previous Transplants:
Previous Transplant Organ Previous Transplant Date Previous Transplant Graft Fail Date
The three most recent transplants are listed here. Please contact the UNet Help Desk to confirm more than three previous transplants by calling 800-978-4334 or by emailing [email protected].
Viral Detection:
HIV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgG:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
CMV IgM:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Core Antibody:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HBV Surface Antigen:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
HCV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
EBV Serostatus:
Positivenmlkj
Negativenmlkj
Not Donenmlkj
UNK/Cannot Disclosenmlkj
Most Recent Hemodynamics: Inotropes/Vasodilators:
PA (sys)mm/Hg:ST=
YES NOnmlkj nmlkj
PA(dia) mm/Hg:ST=
YES NOnmlkj nmlkj
PA(mean) mm/Hg:ST=
YES NOnmlkj nmlkj
PCW(mean) mm/Hg:ST=
YES NOnmlkj nmlkj
CO L/min:ST=
YES NOnmlkj nmlkj
Most Recent Serum Creatinine: mg/dl ST=
Most Recent Total Bilirubin: mg/dl ST=
Oxygen Requirement at Rest: L/min ST=
Chronic Steroid Use: YES NO UNKnmlkj nmlkj nmlkj
Pulmonary Status (Give most recent value):
FVC: %predicted: ST=
FeV1: %predicted: ST=
pCO2: mm/Hg: ST=
Events occurring between listing and transplant:
Transfusions: YES NO UNKnmlkj nmlkj nmlkj
Infection Requiring IV Therapy within 2 wks prior toTx: YES NO UNKnmlkj nmlkj nmlkj
Cerebrovascular Event: YES NO UNKnmlkj nmlkj nmlkj
Dialysis: YES NO UNKnmlkj nmlkj nmlkj
Implantable Defibrillator: YES NO UNKnmlkj nmlkj nmlkj
Episode of Ventilatory Support: YES NO UNKnmlkj nmlkj nmlkj
If yes, indicate most recent timeframe:
At time of transplantnmlkj
Within 3 months of transplantnmlkj
>3 months prior to transplantnmlkj
Tracheostomy: YES NO UNKnmlkj nmlkj nmlkj
Prior Thoracic Surgery other than prior transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, number of prior sternotomies:
Unknown if there were prior sternotomiesnmlkj
0nmlkj
1nmlkj
2nmlkj
3nmlkj
4nmlkj
5+nmlkj
Unknown number of prior sternotomiesnmlkj
If yes, number of prior thoracotomies:
Unknown if there were prior thoracotomiesnmlkj
0nmlkj
1nmlkj
2nmlkj
3nmlkj
4nmlkj
5+nmlkj
Unknown number of prior thoracotomiesnmlkj
Prior congenital cardiac surgery: YES NO UNKnmlkj nmlkj nmlkj
If yes, palliative surgery: YES NO UNKnmlkj nmlkj nmlkj
If yes, corrective surgery: YES NO UNKnmlkj nmlkj nmlkj
If yes, single ventricular physiology: YES NO UNKnmlkj nmlkj nmlkj
Previous Pregnancies:
NO PREVIOUS PREGNANCYnmlkj
1 PREVIOUS PREGNANCYnmlkj
2 PREVIOUS PREGNANCIESnmlkj
3 PREVIOUS PREGNANCIESnmlkj
4 PREVIOUS PREGNANCIESnmlkj
5 PREVIOUS PREGNANCIESnmlkj
MORE THAN 5 PREVIOUS PREGNANCIESnmlkj
NOT APPLICABLE: < 10 years oldnmlkj
UNKNOWNnmlkj
(which may or may not have resulted in a live birth)
Malignancies between listing and transplant: YES NO UNKnmlkj nmlkj nmlkj
This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
If yes, specify type:
Skin Melanomagfedc
Skin Non-Melanomagfedc
CNS Tumorgfedc
Genitourinarygfedc
Breastgfedc
Thyroidgfedc
Tongue/Throat/Larynxgfedc
Lunggfedc
Leukemia/Lymphomagfedc
Livergfedc
Other, specifygfedc
Specify:
Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:
Procedure Type:Heartnmlkj
Heart Lungnmlkj
Was this a retransplant due to failure of a previousthoracic graft: YES NOnmlkj nmlkj
Total Organ Ischemia Time (include cold, warm and anastomotic time):
Heart, Heart-Lung: min ST=
Incidental Tumor found at time of Transplant: YES NO UNKnmlkj nmlkj nmlkj
If yes, specify tumor type:
Adenomanmlkj
Carcinomanmlkj
Carcinoidnmlkj
Lymphomanmlkj
Harmartomanmlkj
Other Primary Lung Tumor, Specifynmlkj
Specify:
Clinical Information : POST TRANSPLANT
Graft Status: Functioning Failednmlkj nmlkj
If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Date of Graft Failure:
Primary Cause of Graft Failure:
Primary Non-Functionnmlkj
Acute Rejectionnmlkj
Chronic Rejection/Atherosclerosisnmlkj
Other, Specifynmlkj
Specify:
Events Prior to Discharge:
Any Drug Treated Infection: YES NO UNKnmlkj nmlkj nmlkj
Stroke: YES NO UNKnmlkj nmlkj nmlkj
Dialysis: YES NO UNKnmlkj nmlkj nmlkj
Cardiac Re-Operation: YES NO UNKnmlkj nmlkj nmlkj
Other Surgical Procedures: YES NO UNKnmlkj nmlkj nmlkj
Time on inotropes other than Isoproterenol (Isuprel): days ST=
Ventilator Support:
Nonmlkj
Ventilator support for <= 48 hoursnmlkj
Ventilator support for >48 hours but < 5 daysnmlkj
Ventilator support >= 5 daysnmlkj
Ventilator support, duration unknownnmlkj
Unknown Statusnmlkj
Reintubated: YES NO UNKnmlkj nmlkj nmlkj
Permanent Pacemaker: YES NO UNKnmlkj nmlkj nmlkj
Chest drain >2 weeks: YES NO UNKnmlkj nmlkj nmlkj
Airway Dehiscence: YES NO UNKnmlkj nmlkj nmlkj
Did patient have any acute rejection episodes betweentransplant and discharge:
Yes, at least one episode treated with anti-rejection agentnmlkj
Yes, none treated with additional anti-rejection agentnmlkj
Nonmlkj
Was biopsy done to confirm acute rejection:
Biopsy not donenmlkj
Yes, rejection confirmednmlkj
Yes, rejection not confirmednmlkj
Treatment
Biological or Anti-viral Therapy: YES NO Unknown/Cannot disclosenmlkj nmlkj nmlkj
If Yes, check all that apply:
Acyclovir (Zovirax)gfedc
Cytogam (CMV)gfedc
Gamimunegfedc
Gammagardgfedc
Ganciclovir (Cytovene)gfedc
Valgancyclovir (Valcyte)gfedc
HBIG (Hepatitis B Immune Globulin)gfedc
Flu Vaccine (Influenza Virus)gfedc
Lamivudine (Epivir) (for treatment of Hepatitis B)gfedc
Other, Specifygfedc
Valacyclovir (Valtrex)gfedc
Specify:
Specify:
Other therapies: YES NOnmlkj nmlkj
If Yes, check all that apply:
Photopheresisgfedc
Plasmapheresisgfedc
Total Lymphoid Irradiation (TLI)gfedc
Immunosuppressive Information
Are any medications given currently for maintenance oranti-rejection: YES NOnmlkj nmlkj
Did the patient participate in any clinical researchprotocol for immunosuppressive medications: YES NOnmlkj nmlkj
If Yes, Specify:
Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Medications
For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications thatwere prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the associatedbox(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acuterejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressivemaintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone, Atgam, Thymoglobulin,OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be recorded as rejection therapyif used for this reason. For each induction medication indicated, write the total number of days the drug was actually administered in the space provided.For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2, even if the second dose was given afterthe patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be eitherlong-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug(example: Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressivemedications given to treat rejection episodes, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode duringthe initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (example:Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (example: from Tacrolimus to Cyclosporine; or fromMycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed undermaintenance immunosuppression.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, Maint, or AR next to OtherImmunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
Ind. Days ST Maint AR
Steroids(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron) gfedc gfedc gfedc
Atgam (ATG) gfedc gfedc gfedc
OKT3 (Orthoclone, Muromonab) gfedc gfedc gfedc
Thymoglobulin gfedc gfedc gfedc
Simulect - Basiliximab gfedc gfedc gfedc
Zenapax - Daclizumab gfedc gfedc gfedc
Azathioprine (AZA, Imuran) gfedc gfedc gfedc
EON (Generic Cyclosporine) gfedc gfedc gfedc
Gengraf (Abbott Cyclosporine) gfedc gfedc gfedc
Other generic Cyclosporine, specify brand: gfedc gfedc gfedc
Neoral (CyA-NOF) gfedc gfedc gfedc
Sandimmune (Cyclosporine A) gfedc gfedc gfedc
CellCept (Mycophenolate Mofetil; MMF) gfedc gfedc gfedc
Generic MMF (Generic CellCept) gfedc gfedc gfedc
Prograf (Tacrolimus, FK506) gfedc gfedc gfedc
Generic Tacrolimus (Generic Prograf) gfedc gfedc gfedc
Advagraf (Tacrolimus Extended or Modified Release) gfedc gfedc gfedc
Nulojix (Belatacept) gfedc gfedc gfedc
Sirolimus (RAPA, Rapamycin, Rapamune) gfedc gfedc gfedc
Myfortic (Mycophenolate Sodium) gfedc gfedc gfedc
Other Immunosuppressive Medications
Ind. Days ST Maint AR
Campath - Alemtuzumab (anti-CD52) gfedc gfedc gfedc
Cyclophosphamide (Cytoxan) gfedc gfedc gfedc
Leflunomide (LFL, Arava) gfedc gfedc gfedc
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc
Rituximab gfedc gfedc gfedc
Investigational Immunosuppressive Medications
Ind. Days ST Maint AR
Zortress (Everolimus) gfedc gfedc gfedc
Other Immunosuppressive Medication, Specify gfedc gfedc gfedc