11f Post 5-Year Kidney Pediatric Follow-up

Records
Post 5 Year Pediatric Transplant Recipient Follow-Up Worksheet
The revised worksheet sample is for reference purposes only and is pending OMB approval.
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI
other data may be provided. Based on data provided through the online TIEDI
fields are not required in every case, they are not marked with a red asterisk.

B.

B.

application. Currently in the worksheet, a red asterisk is displayed by fields that are required, independent of what

application, additional fields that are dependent on responses provided in these required fields may become required as well. However, since those

Recipient Information
Name:

DOB:

SSN:

Gender:

HIC:

Tx Date:

Previous Follow-Up:

Previous Px Stat Date:

Transplant Discharge Date:
State of Permanent Residence:
Zip Code:

-

Provider Information
Recipient Center:
Followup Center:

Donor Information
UNOS Donor ID #:
Donor Type:

Patient Status
Date: Last Seen, Retransplanted or Death

j LIVING
k
l
m
n
j DEAD
k
l
m
n

Patient Status:

j RETRANSPLANTED
k
l
m
n

Primary Cause of Death:
Specify:

Functional Status:

j Definite Cognitive delay/impairment (verified by IQ score <70 or unambiguous behavioral observation)
k
l
m
n
j Probable Cognitive delay/impairment (not verified or unambiguous but more likely than not, based on
k
l
m
n
behavioral observation or other evidence)
j Questionable Cognitive delay/impairment (not judged to be more likely than not, but with some indication
k
l
m
n
of cognitive delay/impairment such as expressive/receptive language and/or learning difficulties)

Cognitive Development:

j No Cognitive delay/impairment (no obvious indicators of cognitive delay/impairment)
k
l
m
n
j Not Assessed
k
l
m
n

j Definite Motor delay/impairment (verified by physical exam or unambiguous behavioral observation)
k
l
m
n
j Probable Motor delay/impairment (not verified or unambiguous but more likely than not, based on
k
l
m
n
behavioral observation or other evidence)
j Questionable Motor delay/impairment (not judged to be more likely than not, but with some indications of
k
l
m
n
motor delay/impairment)

Motor Development:

j No Motor delay/impairment (no obvious indicators of motor delay/impairment)
k
l
m
n
j Not Assessed
k
l
m
n

Clinical Information
Date of Measurement:
Height:

ft.

Weight:

lbs.

BMI:

in.

cm

%ile

ST=

kg

%ile

ST=

kg/m2

%ile

Kidney Clinical Information
Graft Status:

j Functioning n
k
l
m
n
j Failed
k
l
m

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 Failure:
Primary Cause of Graft Failure:

Other, Specify:
If Functioning, Most Recent Serum Creatinine:

Diabetes onset during the follow-up period:
If yes, insulin dependent:

mg/dl

St=

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Coronary artery disease since last follow-up:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Transplant Malignancies:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Donor Related:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Recurrence of Pre-Tx Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Tx De Novo Solid Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

De Novo Lymphoproliferative disease and Lymphoma:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Kidney/Pancreas Clinical Information
Kidney Graft Status:

j Functioning n
k
l
m
n
j Failed
k
l
m

If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
If Functioning, Most Recent Serum Creatinine:

mg/dl

St=

Kidney Primary Cause of Graft Failure:
Primary, Other Specify:
Kidney Date of Failure:

Pancreas Graft Status:

j Functioning n
k
l
m
n
j Failed
k
l
m
j Partial Function n
k
l
m

If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.
Pancreas Date of Failure:
Pancreas Primary Cause of Graft Failure:
Primary, Other Specify:
Contributory Causes Of Graft Failure:
Contributory: Pancreas Graft/Vascular Thrombosis:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Pancreas Infection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Pancreas Bleeding:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Anastomotic Leak:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Pancreas Acute Rejection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Pancreas Chronic Rejection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Biopsy Proven Isletitis:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Pancreatitis:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Patient Noncompliance

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Other, Specify:

Diabetes onset during the follow-up period:
If yes, insulin dependent:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Coronary artery disease since last follow-up:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Transplant Malignancies:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Donor Related:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Recurrence of Pre-Tx Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Tx De Novo Solid Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

De Novo Lymphoproliferative disease and Lymphoma:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Pancreas Clinical Information
Graft Status:

j Functioning n
k
l
m
n
j Failed
k
l
m
j Partial Function n
k
l
m

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 Failure:
Primary Cause of Graft Failure:
Primary, Other Specify:
Contributory Causes Of Graft Failure:
Contributory: Graft/Vascular Thrombosis:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Infection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Bleeding:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Anastomotic Leak:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Acute Rejection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Chronic Rejection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Biopsy Proven Isletitis:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Pancreatitis:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Patient Noncompliance

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Contributory: Other, Specify:

Most Recent Serum Creatinine:

Diabetes onset during the follow-up period:
If yes, insulin dependent:

mg/dl

St=

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Coronary artery disease since last follow-up:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Transplant Malignancies:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Donor Related:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Recurrence of Pre-Tx Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Tx De Novo Solid Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

De Novo Lymphoproliferative disease and Lymphoma:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Intestine Clinical Information
Graft Status:

j Functioning n
k
l
m
n
j Failed
k
l
m

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 Failure:
Primary Cause of Graft Failure:
Primary, Other Specify:

Most Recent Serum Creatinine:

Diabetes onset during the follow-up period:
If yes, insulin dependent:

mg/dl

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

St=

Coronary artery disease since last follow-up:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Transplant Malignancies:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Donor Related:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Recurrence of Pre-Tx Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Tx De Novo Solid Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

De Novo Lymphoproliferative disease and Lymphoma:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Liver Clinical Information
Graft Status:

j Functioning n
k
l
m
n
j Failed
k
l
m

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 Failure:
Contributory Causes Of Graft Failure:
Primary Graft Failure

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Vascular Thrombosis

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Hepatic arterial thrombosis

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Hepatic outflow obstruction

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Portal vein thrombosis

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Biliary Tract Complication:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Denovo Hepatitis

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Recurrent Hepatitis:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Recurrent Disease:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Acute Rejection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Chronic Rejection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Infection:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Other, Specify:

Most Recent Serum Creatinine:

Diabetes onset during the follow-up period:
If yes, insulin dependent:

mg/dl

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Coronary artery disease since last follow-up:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Transplant Malignancies:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Donor Related:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Recurrence of Pre-Tx Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Tx De Novo Solid Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

De Novo Lymphoproliferative disease and Lymphoma:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Thoracic Clinical Information
Graft Status:

j Functioning n
k
l
m
n
j Failed
k
l
m

If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.

j Primary Non-Function
k
l
m
n

St=

j Acute Rejection
k
l
m
n
Primary Cause of Graft Failure:

j Chronic Rejection/Atherosclerosis
k
l
m
n
j Other specify
k
l
m
n

Date of Failure:

Coronary Artery Disease Since Last Follow Up:

Most Recent Serum Creatinine:

Diabetes onset during the follow-up period:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

mg/dl

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

If yes, insulin dependent:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Transplant Malignancies:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Donor Related:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Recurrence of Pre-Tx Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Post Tx De Novo Solid Tumor:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

De Novo Lymphoproliferative disease and Lymphoma:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

St=