records adult kidney transplant recipient registration ... · records adult kidney transplant...

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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 unethelpdesk@unos.org.

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