The Transplant Recipient Registration (TRR) records are generated and available immediately after a transplant event is reported through the recipient feedback process in WaitlistSM. A TRR will also be generated in the case of a living donor transplant, where a recipient was added through the donor feedback process in Tiedi®. The TRR record is completed by the transplant center performing the transplant. The registration and hospital discharge follow-up information is combined in this record.
Complete the TRR at hospital discharge or six weeks post transplant, whichever is first. If the recipient is still hospitalized at six weeks post transplant, provide the most recent information available regarding the recipient's progress.
The TRR record must be completed within 60 days from the record generation date. See OPTN/UNOS Policies for additional information. Use the search feature to locate specific policy information on Data Submission Requirements.
To correct information that is already displayed on an electronic record, call the UNetSM Help Desk at 1-800-978-4334.
Recipient Information
Name: Verify the last name, first name and middle initial of the transplant recipient is correct. If the information is incorrect, corrections may be made on the recipient's TCR record.
DOB: Verify the displayed date is the recipient's date of birth. If the information is incorrect, corrections may be made on the recipient's TCR record.
SSN: Verify the recipient's social security number is correct. If the information is incorrect, contact the Help Desk at 1-800-978-4334.
Gender: Verify the recipient's gender is correct. If the information is incorrect, corrections may be made on the recipient's TCR record.
HIC: Verify the 9 to 11 character Health Insurance Claim number for the recipient indicated on the recipient's most recently updated TCR record is correct. If the recipient does not have a HIC number, you may leave this field blank.
Tx Date: Verify the displayed transplant date is the date of the beginning of the first anastomosis. If the operation started in the evening and the first anastomosis began early the next morning, the transplant date is the date that the first anastomosis began. The transplant is considered complete when the cavity is closed and the final skin stitch/staple is applied. The transplant date is indicated immediately after a transplant event is reported through the recipient feedback process in Waitlist and in the case of a living donor transplant, where a recipient was added through the donor feedback process in Tiedi.
State of Permanent Residence: Select the name of the state, of the recipient's permanent address, at the time of transplant. (List of State codes)
Permanent Zip: Enter the recipient's zip code, of their permanent address, at the time of transplant.
Provider Information
Recipient Center: The recipient center will display. Verify that the transplant center name, center code, and the provider number, (6-character Medicare identification number of the hospital where the transplant recipient was transplanted) are correct.
Surgeon Name: Enter the name of the primary surgeon, who performed the transplant operation, and under whose name the transplant is billed.
NPI #: Enter the 10-character CMS (Center for Medicare and Medicaid Services, formerly HCFA) assigned National Provider Identifier of the transplant physician. Your hospital billing office may be able to obtain this number for you.
Donor Information
UNOS Donor ID #: The UNOS Donor ID number, reported in the Recipient Feedback, will display. Each potential donor is assigned an identification number by OPTN/UNOS. This ID number corresponds to the date the donor information was entered into the OPTN/UNOS computer system.
Donor Type: The donor type, reported in the Recipient Feedback, will display. Verify the recipient's donor type is correct. If the information is incorrect, contact the Help Desk at 1-800-978-4334.
Deceased indicates the donor was not living at the time of
donation.
Living indicates the donor was living at the
time of donation.
Patient Status
Primary Diagnosis: Select the primary diagnosis for the disease requiring a transplant for this recipient. If the recipient has had a previous transplant for the same organ type, select Retransplant/Graft Failure as the primary diagnosis for that organ. If Other, Specify is selected, enter the primary diagnosis in the space provided. (List of Intestine Diagnosis codes)
Secondary Diagnosis: Select the secondary diagnosis ffor the disease requiring a transplant for this recipient. If Other, Specify is selected, enter the secondary diagnosis in the space provided. (List of Intestine Diagnosis codes)
Date: Last Seen, Retransplanted or Death: Enter the date the hospital reported the recipient as living, retransplanted (when the data was obtained prior to the recipient's discharge) or the date of the recipient's death, using the standard 8-digit numeric format of MM/DD/YYYY.
Patient Status: Select the appropriate status for this recipient. If Dead is selected, indicate the cause of death. (List of Patient Status codes)
Living
Dead
Retransplanted
Primary Cause of Death: If the Patient Status is Dead, select the patient's cause of death. If an Other code is selected, enter the other cause of death in the space provided. (List of Primary Cause of Death codes)
Contributory Cause of Death: If the Patient Status is Dead, select the patient's contributory cause of death. If an Other code is selected, enter the other cause of death in the space provided. (List of Contributory Cause of Death codes)
Contributory Cause of Death: If the Patient Status is Dead, select the patient's contributory cause of death. If an Other code is selected, enter the other cause of death in the space provided. (List of Contributory Cause of Death codes)
Note: If the patient is being retransplanted, access the patient's last record for their previous transplant and select Retransplanted in the Patient Status field. This will stop the generation of TRF records associated with the previous transplant.
Transplant Hospitalization:
Date of Admission to Tx Center: Enter the date the recipient was admitted to the transplant center, using the 8-digit MM/DD/YYYY format. If the patient was admitted to the hospital before it was determined a transplant was needed, enter the date it was determined the patient needed a transplant.
Date of Discharge From Tx Center: Enter the date the recipient was released to go home, using the 8-digit MM/DD/YYYY format. The recipient's hospital stay includes total time spent in different units of the hospital, including medical and rehab. This information is not required in the TRR record, but if entered here, it will automatically fill in the future TRF records. It is required in the TRF record.
Note: Leave this field blank if the recipient was removed from the waiting list with a code of 21, indicating the recipient died during the transplant procedure.
Was patient hospitalized during the last 90 days prior to the transplant admission: If the recipient was hospitalized during the last 90 days prior to transplant admission, select Yes. If not, select No. If unknown, select UNK. (This field is optional.)
Medical Condition at time of transplant: Select the choice that best describes the recipient's condition and location just prior to the time of transplant. (List of Medical Condition codes)
In Intensive
Care Unit
Hospitalized
Not in ICU
Not
Hospitalized
Life Support: If the patient was on life support at the time of transplant, select Yes. If not, select No. If Yes is selected, check all that apply. If a type of life support used is not listed select Other Mechanism, Specify and specify the type in the space provided.
Ventilator
- Select only if the recipient is on continuous invasive
ventilation
Artificial
Liver
Other
Mechanism, Specify
Functional Status: Select the choice that best describes the recipient's functional status just prior to the time of transplant. (List of Functional Status codes)
Note: The Karnofsky Index will display for adults aged 18 and older.
10% - Moribund, fatal processes progressing rapidly
20% - Very
sick, hospitalization necessary: active treatment necessary
30%
- Severely disabled: hospitalization is indicated, death not
imminent
40% - Disabled: requires special care and
assistance
50% - Requires considerable assistance and frequent
medical care
60% - Requires occasional assistance but is able to
care for needs
70% - Cares for self: unable to carry on normal
activity or active work
80% - Normal activity with effort: some
symptoms of disease
90% - Able to carry on normal activity:
minor symptoms of disease
100% - Normal, no complaints, no
evidence of disease
Unknown
Note: The Lansky Scale will display for pediatrics aged 1 to 17.
10% - No play; does not get out of bed
20% - Often sleeping;
play entirely limited to very passive activities
30% - In bed;
needs assistance even for quiet play
40% - Mostly in bed;
participates in quiet activities
50% - Can dress but lies around
much of day; no active play; can take part in quiet
play/activities
60% - Up and around, but minimal active play;
keeps busy with quieter activities
70% - Both greater
restriction of and less time spent in play activity
80% -
Active, but tires more quickly
90% - Minor restrictions in
physically strenuous activity
100% - Fully active, normal
Not
Applicable (patient < 1 year old)
Unknown
Note: This evaluation should be in comparison to the person's normal function, indicating how the patient's disease has affected their normal function.
Physical Capacity: (Complete for recipients older than 18 years of age.) Select the choice that best describes the recipient's physical capacity just prior to the time of transplant. If the recipient's Medical Condition indicates they are hospitalized, select Not Applicable (hospitalized). (This field is optional for adult recipients only.) (List of Physical Capacity codes)
No
Limitations
Limited
Mobility
Wheelchair
bound or more limited
Not
Applicable (hospitalized)
Unknown
Physical Capacity is the ability to perform bodily activities such as walking, dressing, bathing, grooming, etc.
Cognitive Development: (Complete for recipients 18 years of age or younger.) Select the choice that best describes the recipient's cognitive development just prior to the time of transplant.
Definite Cognitive Delay/Impairment (verified by IQ score <70 or unambiguous behavioral observation)
Probable Cognitive Delay/Impairment (not verified or unambiguous but more likely than not, based on behavioral observation or other evidence)
Questionable Cognitive Delay/Impairment (not judged to be more likely than not, but with some indication of cognitive delay/impairment such as expressive/receptive language and/or learning difficulties)
No Cognitive Delay/Impairment (no obvious indicators of cognitive delay/impairment)
Not Assessed
Motor Development: (Complete for recipients 18 years of age or younger.) Select the choice that best describes the recipient's motor development just prior to the time of transplant. (List of Motor Development codes)
Definite Motor Delay/Impairment (verified by physical exam or unambiguous behavioral observation)
Probable Motor Delay/Impairment (not verified or unambiguous but more likely than not, based on behavioral observation or other evidence)
Questionable Motor Delay/Impairment (not judged to be more likely than not, but with some indication of motor delay/impairment)
No Motor Delay/Impairment (no obvious indicators of motor delay/impairment)
Not Assessed
Working for income: (Complete for recipients 19 years of age or older.) If the recipient was working for income just prior to the time of transplant, select Yes. If not, select No. If reporting the recipient's death, indicate if the recipient was working for income just prior to death.
If No, Not Working Due To: If No is selected, indicate the reason why the candidate is not working just prior to the time of transplant. (This field is optional for adult candidates only.) (List of Not Work Reason codes)
Disability - A physical or mental impairment that interferes with or prevents a candidate from working (e.g. arthritis, mental retardation, cerebral palsy, etc).
Demands of Treatment - An urgent medical treatment that prevents a candidate from working (e.g. dialysis).
Insurance Conflict - Any differences between a candidate and insurance company that prevents them from working.
Inability to Find Work - The lack of one's ability to find work (e.g. lack of transportation, work experience, over qualification, unavailable work, etc.).
Patient Choice - Homemaker - A candidate who chooses to manage their own household, instead of performing work for pay.
Patient Choice - Student Full Time/Part Time - A candidate who is enrolled and/or participating in college.
Patient Choice - Retired - A candidate who no longer has an active working life such as an occupation, business or office job.
Patient Choice - Other - Any reason not listed above that would prevent a candidate from working.
Not Applicable - Hospitalized - Select only if the patient's Medical Condition indicates they are in the hospital.
Unknown
If Yes: If Yes is selected, indicate the candidate's working status just prior to the time of transplant. (This field is optional for adult candidates only.) (List of Working codes)
Working Full Time
Working Part Time due to Demands of
Treatment
Working Part Time due to Disability
Working Part
Time due to Insurance Conflict
Working Part Time due to
Inability to Find Full Time Work
Working Part Time due to
Patient Choice
Working Part Time Reason Unknown
Working,
Part Time vs. Full Time Unknown
Academic Progress: (Complete for recipients less than 19 years of age.) Select the choice that best describes the recipient's academic progress just prior to the time of transplant. If the candidate is less than 5 years old or has graduated from high school, select Not Applicable < 5 years old/High School graduate or GED. (List of Academic Progress codes)
Within One Grade Level of Peers
Delayed Grade Level
Special
Education
Not Applicable <5 years old/High School graduate or
GED
Status Unknown
Academic Activity Level: (Complete for recipients less than 19 years of age.) Select the choice that best describes the recipient's academic activity level just prior to the time of transplant. If the recipient is less than 5 years old or has graduated from high school, select Not Applicable < 5 years old/High School graduate or GED. (List of Academic Activity Level codes)
Full academic load
Reduced academic load
Unable to
participate in academics due to disease or condition
Unable
to participate regularly in academics due to dialysis
Not
Applicable <5 years old/High School graduate or GED
Status
Unknown
Source of Payment:
Primary: Select as appropriate to indicate the recipient's source of primary payment (largest contributor) for the transplant. (List of Primary Insurance codes)
Private insurance refers to funds from agencies such as Blue Cross/Blue Shield, etc. It also refers to any worker's compensation that is covered by a private insurer.
Public insurance - Medicaid refers to state Medicaid funds.
Public insurance - Medicare FFS (Fee-for-Service) refers to funds from the government in which doctors and other health care providers are paid for each service provided to a recipient. For additional information about Medicare, see http://www.medicare.gov/Choices/Overview.asp.
Public insurance - Medicare & Choice (also known as Medicare Managed Care) refers to funds from the government in which doctors and other health care providers are paid for each service provided to a recipient, along with additional benefits such as coordination of care or reducing-out-of-pocket expenses. Sometimes a recipient may receive additional benefits such as prescription drugs. For additional information about Medicare, see http://www.medicare.gov/Choices/Overview.asp.
Public insurance - CHIP (Children's Health Insurance Program)
Public insurance - Department of VA refers to funds from the Veterans Administration.
Public insurance - Other government
Self indicates that the recipient will pay for the cost of transplant.
Donation indicates that a company, institution, or individual(s) donated funds to pay for the transplant and care of the recipient.
Free Care indicates that the transplant hospital will not charge recipient for the costs of the transplant operation.
Foreign Government, Specify refers to funds provided by a foreign government (Primary only) Specify foreign country in the space provided. (List of Foreign Country codes)
Secondary: Select check as appropriate to indicate the recipient's source of secondary payment. (This field is optional.) (List of Secondary Insurance codes)
Private insurance refers to funds from agencies such as Blue Cross/Blue Shield, etc. It also refers to any worker's compensation that is covered by a private insurer.
Public insurance - Medicaid refers to state Medicaid funds.
Public insurance - Medicare FFS (Fee-for-Service) refers to funds from the government in which doctors and other health care providers are paid for each service provided to a recipient. For additional information about Medicare, see http://www.medicare.gov/Choices/Overview.asp.
Public insurance - Medicare & Choice (also known as Medicare Managed Care) refers to funds from the government in which doctors and other health care providers are paid for each service provided to a recipient, along with additional benefits such as coordination of care or reducing-out-of-pocket expenses. Sometimes a recipient may receive additional benefits such as prescription drugs). For additional information about Medicare, see http://www.medicare.gov/Choices/Overview.asp.
Public insurance - CHIP (Children's Health Insurance Program)
Public insurance - Other government
Self indicates that the recipient will pay for the cost of transplant.
Donation indicates that a company, institution, or individual(s) donated funds to pay for the transplant and care of the recipient.
Free Care indicates that the transplant hospital will not charge the recipient for the costs of the transplant operation.
None - Select if the recipient does not have a secondary source of payment.
Clinical Information: Pretransplant
Date of Measurement: (Complete for recipients 18 years of age or younger.) Enter the date, using the 8-digit format of MM/DD/YYYY, the recipient’s height and weight were measured.
Height: Enter the height of the recipient, just prior to the time of transplant, in feet and inches or centimeters. If the recipient’s height is unavailable, select the appropriate status from the ST field (N/A, Not Done, Missing, Unknown). (List of Status codes) For recipients 18 years old or younger at the time of transplant, UNet will generate and display calculated percentiles based on the 2000 CDC growth charts.
Weight: Enter the weight of the recipient, just prior to the time of transplant, in pounds or kilograms. If the recipient’s weight is unavailable, select the appropriate status from the ST field (N/A, Not Done, Missing, Unknown). (List of Status codes) For recipients 18 years old or younger at the time of transplant, UNet will generate and display calculated percentiles based on the 2000 CDC growth charts.
BMI (Body Mass Index): The recipient's BMI will display. For candidates less than 20 years of age at the time of transplant, UNet will generate and display calculated percentiles based on the 2000 CDC growth charts.
Percentiles are the most commonly used clinical indicator to assess the size and growth patterns of individual children in the United States. Percentiles rank the position of an individual by indicating what percent of the reference population the individual would equal or exceed (i.e. on the weight-for-age growth charts, a 5 year-old girl whose weight is at the 25th percentile, weighs the same or more than 25 percent of the reference population of 5-year-old girls, and weighs less than 75 percent of the 5-year-old girls in the reference population). For additional information about CDC growth charts, see http://www.cdc.gov/.
Note: Users who check the BMI percentiles against the CDC calculator may notice a discrepancy that is caused by the CDC calculator using 1 decimal place for height and weight and UNetsm using 4 decimal places for weight and 2 for height.
Previous Transplants: The three most recent transplant(s), indicated on the recipient's validated Transplant Recipient Registration (TRR) record(s), will display. Verify all previous transplants listed by organ type, transplant date and graft failure date.
Note: The three most recent transplants on record for this recipient will be displayed for verification. If there are any prior transplants that are not listed here, contact the UNet Help Desk at 1-800-978-4334 or [email protected] to determine if the transplant event is in the database.
Viral Detection:
HIV Serostatus: Select the serology results from the drop-down list.
Positive
Negative
Not Done
UNK/Cannot Disclose
Definition: Human Immunodeficiency Virus - Any of several retroviruses and especially HIV-1 that infect and destroy helper T cells of the immune system causing the marked reduction in their numbers that is diagnostic of AIDS.
CMV IgG: Select the serology results from the drop-down list.
Positive
Negative
Not Done
UNK/Cannot Disclose
Definition: Cytomegalovirus - A herpesvirus (genus Cytomegalovirus) that causes cellular enlargement and formation of eosinophilic inclusion bodies especially in the nucleus and that acts as an opportunistic infectious agent in immunosuppressed conditions (as AIDS).
CMV IgM: Select the serology results from the drop-down list.
Positive
Negative
Not Done
UNK/Cannot Disclose
Definition: Cytomegalovirus - A herpesvirus (genus Cytomegalovirus) that causes cellular enlargement and formation of eosinophilic inclusion bodies especially in the nucleus and that acts as an opportunistic infectious agent in immunosuppressed conditions (as AIDS).
HBV Core Antibody: Select the serology results from the drop-down list.
Positive
Negative
Not Done
UNK/Cannot Disclose
Definition: Hepatitis B Virus - A sometimes fatal hepatitis caused by a double-stranded DNA virus (genus Orthohepadnavirus of the family Hepadnaviridae) that tends to persist in the blood serum and is transmitted especially by contact with infected blood (as by transfusion or by sharing contaminated needles in illicit intravenous drug use) or by contact with other infected bodily fluids (as during sexual intercourse) -- also called serum hepatitis.
HBV Surface Antigen: Select the serology results from the drop-down list.
Positive
Negative
Not Done
UNK/Cannot Disclose
Definition: Hepatitis B Virus - A sometimes fatal hepatitis caused by a double-stranded DNA virus (genus Orthohepadnavirus of the family Hepadnaviridae) that tends to persist in the blood serum and is transmitted especially by contact with infected blood (as by transfusion or by sharing contaminated needles in illicit intravenous drug use) or by contact with other infected bodily fluids (as during sexual intercourse) -- also called serum hepatitis.
HCV Serostatus: Select the serology results from the drop-down list.
Positive
Negative
Not Done
UNK/Cannot Disclose
Definition: Hepatitis C Virus - A disease caused by a flavivirus that is usually transmitted by parenteral means (as injection of an illicit drug, blood transfusion, or exposure to blood or blood products) and that accounts for most cases of non-A, non-B hepatitis.
EBV Serostatus: Select the serology results from the drop-down list.
Positive
Negative
Not Done
UNK/Cannot Disclose
Definition: (Epstein-Barr Virus) - A herpesvirus (genus Lymphocryptovirus) that causes infectious mononucleosis and is associated with Burkitt's lymphoma and nasopharyngeal carcinoma -- abbreviation EBV; called also EB virus.
Total Bilirubin: Enter the lab value for total serum bilirubin in mg/dl taken closest to the time of transplant. If the value is not available, select the appropriate status from the ST field (N/A,Not Done,Missing,Unknown). (List of Status codes)
Serum Albumin: Enter the lab value for the serum albumin value in g/dl taken closest to the time of transplant. If the value is not available, select the appropriate status from the ST field (N/A,Not Done,Missing,Unknown). (List of Status codes)
Serum Creatinine: Enter the lab value for the serum creatinine value in mg/dl taken closest to the time of transplant. If the value is not available, select the appropriate status from the ST field (N/A,Not Done,Missing,Unknown). (List of Status codes)
Malignancies between listing and transplant: If the recipient has a history of any malignancies between listing and transplant, select Yes. If the recipient has not had a history of any malignancies between listing and transplant, select No. If unknown, select UNK. If Yes is selected, select the type(s) of malignancy. If Other, Specify is selected, indicate the type of tumor in the space provided. (List of Adult Malignancy codes) (List of Pediatric Malignancy codes)
Skin Melanoma
Skin Non-Melanoma
CNS
Tumor
Genitourinary
Breast
Thyroid
Tongue/Throat/Larynx
Lung
Leukemia/Lymphoma
Liver
Hepatoblastoma
(This selection is available to pediatric recipients
only.)
Hepatocellular Carcinoma Other, specify
Note: This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.
Clinical Information: Transplant Procedure
Multiple Organ Recipient: Other organs, that were reported as being transplanted in the Recipient Feedback, will display. Verify the other organs transplanted at this time are correct. If incorrect, contact the Help Desk.
Were extra vessels used in the tx procedure: If extra vessels (vascular allografts) were used in the transplant procedure, as indicated on the Waitlist Removal, Yes displays.
Vessel Donor ID: The Donor ID entered on the Waitlist Removal displays.
Note: Donor IDs entered for this question must be from deceased donors. All deceased donor extra vessels must be
monitored due to the potential for disease transmission.
Note: If the extra vessels used in a transplant procedure are procured from a tissue processing organization, they are not reported in UNet.
Procedure Information:
Intestine Only Venous Drainage: Indicate if the intestinal venous drainage was attached to Portal or Systemic circulation.
Native Viscera Venous Drainage: Indicate if the native viscera venous drainage was attached to Portal or Systemic circulation.
Procedure Type: Verify that the displayed procedure type is correct. (List of Procedure Type codes)
Whole
Intestine
Intestine
Segment
Whole
Intestine with Pancreas (Technical Reasons)
Intestine
Segment with Pancreas (Technical Reasons)
Organ Type: Select to indicate all intestinal organs transplanted into this recipient from the donor identified on the list below.
Stomach
Small
Intestine
Duodenum
Large
Intestine
Preservation Information:
Total Ischemic Time (Include cold, warm and anastomotic time): Enter the cumulative time between cessation of blood flow in the donor and revascularization of the intestinal organ in the recipient. If the time is not available, select the appropriate status from the ST field (N/A, Not Done,Missing, Unknown).
Note: Enter the time in
hours and decimal parts of an hour. For example, 1 hour should be
entered as "1", "1.0" or "1.00"; 1 hour
and 30 minutes should be entered as "1.5" or "1.50"
not "1.30".
To
report the minutes, divide the number of minutes into 60 and
record 2 decimal places. Example:
7hrs 19 minutes = 7.32 ( 60 divided by 19 =.32)
Note: Select N/A from the ST field for all Preservation Information if the recipient was removed from the waiting list with a code 21, indicating the recipient died during the transplant procedure.
Risk Factors: For each of the risk factors listed, indicate the recipient's history of the risk factor at the time of this transplant.
Recent Septicemia: If the recipient has a history of septicemia requiring IV antibiotic medication during the two weeks prior to transplant select Yes. If not, select No. If unknown, select UNK.
Exhausted Vascular Access: If the medical staff is unable to access the recipients vascular system for intravenous therapy at the time of transplant, select Yes. If not, select No. If unknown, select UNK.
Liver Dysfunction: If the recipient has liver dysfunction evidenced by elevated liver function studies at the time of transplant, select Yes. If not, select No. If unknown, select UNK. This field is optional.
Previous Abdominal Surgery: If the recipient had any abdominal surgery prior to this transplant, select Yes. If not, select No. If unknown, select UNK.
Number Previous Abdominal Surgeries: Indicate the number of previous abdominal surgeries in the space provided. If the number of surgeries is not available, select the appropriate status from the ST field (N/A,Not Done,Missing,Unknown). This field is optional.
Dilated/Non-Functional Bowel Segments: If the recipient exhibited any dilated or non-functioning bowel segments at the time of transplant, select Yes. If not, select No. If unknown, select UNK.
Other: If other risk factors were present at the time of transplant, enter the factors in the space provided.
Clinical Information: Post Transplant
Graft Status: If the graft is functioning at the time of hospital discharge or six weeks post-transplant, select Functioning. If the graft is not functioning at the time of hospital discharge or six weeks post-transplant, select Failed.
Note: Select Functioning if the recipient was removed from the waiting list with a code 21, indicating the recipient died during the transplant procedure.
Note: 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, select Yes or No for each of the following fields:
TPN Dependent: If the recipient is dependent on total parenteral nutrition, select Yes. If not, select No.
IV Dependent: If the recipient is dependent on intravenous fluids, select Yes. If not, select No.
Oral Feeding: If the recipient is receiving oral nutrition, select Yes. If not, select No.
Tube Feeding: If the recipient is receiving nutrition via any gastric tube, select Yes. If not, select No.
If Failed, provide the following information:
Date of Failure: Enter the date of graft failure using the standard 8-digit numeric format of MM/DD/YYYY.
Primary Causes of Graft Failure: For each cause of graft failure listed, select Yes, No, or UNK. If Other Specify is selected, enter the cause of graft failure in the space provided. (List of Adult Graft Failure codes) (List of Pediatric Graft Failure codes)
Recurrent
Tumor
Acute
Rejection
Chronic
Rejection
Technical
Problems
Infection
Lymphoproliferative
Disease
GVHD
(Graft
vs. Host Disease) (This selection is
available to pediatric recipients only.)
Ischemia/NEC
(Necrotizing
Enterocolitis) Like
Syndrome (This selection is available to
pediatric recipients only.)
Other
Specify
Did patient have any acute rejection episodes between transplant and discharge: If the recipient had any acute rejection episodes between transplant and discharge, select a Yes choice. If not, select No. If a Yes choice is selected, then indicate if a biopsy was done to confirm acute rejection. (List of Any Acute Rejection Episodes codes)
Yes, at least one episode treated with anti-rejection agent
Yes,
none treated with additional anti-rejection agent
No
Was Biopsy done to confirm acute rejection: If the recipient had an acute kidney rejection episode, indicate whether biopsy confirmed acute rejection by selecting Yes. If a biopsy was not done, select Biopsy not done. If unknown, select Unknown. This field is optional. (List of Biopsy Confirmed codes)
Biopsy not done
Yes, rejection confirmed
Yes, rejection
not confirmed
Treatment
Biological or Anti-viral Therapy: If biological or anti-viral therapy is being administered to the recipient, select Yes. If not, select No. If unknown or can't disclose, select Unknown/Cannot Disclose. If Yes is selected, check all that apply. If a therapy, other than those listed, was administered, select Other, Specify and enter the therapy in the space provided. These fields are optional. (List of Anti-viral Treatment codes)
Acyclovir (Zovirax)
Cytogam
(CMV)
Gamimune
Gammagard
Ganciclovir
(Cytovene)
Valgancyclovir (Valcyte)
HBIG (Hepatitis B
Immune Globulin)
Flu Vaccine (Influenza Virus)
Lamivudine
(Epivir) (for treatment of Hepatitis B)
Valacyclovir
(Valtrex)
Other, Specify
Other Therapies: If the recipient received other therapies, select Yes. If not, select No. If Yes is selected, check all that apply. These fields are optional. (List of Other Therapies codes)
Photopheresis
Plasmapheresis
Total Lymphoid Irradiation
(TLI)
Note: If the recipient was removed from the waiting list with a code 21, indicating the recipient died during the transplant procedure, select No for all Biologicals or Anti-viral.
Immunosuppressive Information
Are any medications given currently for maintenance or anti-rejection: If medications have been given to the recipient for maintenance or anti-rejection during the time between transplant and hospital discharge, or 6 weeks post-transplant if the recipient has not been discharged, select Yes. If not, select No. If Yes, complete the sections below.
Did the recipient participate in any clinical research protocol for immunosuppressive medications: If the recipient participated in clinical research for immunosuppressive medications, select Yes. If not, select No. If Yes, specify in the space provided. These fields are optional.
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 associated box blank.
Induction (Ind.) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acute rejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressive maintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (e.g., 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 therapy if used for this reason. For each induction medication indicated, enter 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 after the patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be either long-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug (e.g., Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressive medications 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 during the initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (e.g., Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (e.g., from Tacrolimus to Cyclosporine; or from Mycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed under maintenance immunosuppression.
Note: As further clarification, drugs that are used with the intention to maintain recipients long-term are medications such as Tacrolimus, Cyclosporine, Azathioprine, Mycophenolate Mofetil and Prednisone. These maintenance medications should not be listed as AR medications to treat acute rejection. When patients have a true acute rejection, they are given anti-rejection medication such as steroids, OKT3, ATG, Simulect and Zenapax, in addition to the maintenance medications. These are the medications that should be selected as anti-rejection.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind., Maint, or AR next to Other Immunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
If the number of days is unavailable, select the appropriate status from the applicable Status field (N/A, Not Done, Missing, Unknown).(List of Status codes)
Other 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 associated box blank.
Induction (Ind.) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acute rejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressive maintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (e.g., 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 therapy if used for this reason. For each induction medication indicated, enter 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 after the patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be either long-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug (e.g., Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressive medications 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 during the initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (e.g., Methylprednisolone, Atgam, OKT3, or Thymoglobulin). When switching maintenance drugs (e.g., from Tacrolimus to Cyclosporine; or from Mycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed under maintenance immunosuppression.
Note: As further clarification, drugs that are used with the intention to maintain recipients long-term are medications such as Tacrolimus, Cyclosporine, Azathioprine, Mycophenolate Mofetil and Prednisone. These maintenance medications should not be listed as AR medications to treat acute rejection. When patients have a true acute rejection, they are given anti-rejection medication such as steroids, OKT3, ATG, Simulect and Zenapax, in addition to the maintenance medications. These are the medications that should be selected as anti-rejection.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind., Maint, or AR next to Other Immunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
If the number of days is unavailable, select the appropriate status from the applicable Status field (N/A, Not Done, Missing, Unknown).(List of Status codes)
Investigational 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 associated box blank.
Induction (Ind.) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing acute rejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for immunosuppressive maintenance. 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 therapy if used for this reason. For each induction medication indicated, enter 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 after the patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant for varying periods of time which may be either long-term or intermediate term with a tapering of the dosage until the drug is either eliminated or replaced by another long-term maintenance drug (e.g., Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine, or Rapamycin). This does not include any immunosuppressive medications 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 during the 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 from Mycophenolate Mofetil to Azathioprine) because of rejection, the drugs should not be listed under AR immunosuppression, but should be listed under maintenance immunosuppression.
Note: As further clarification, drugs that are used with the intention to maintain recipients long-term are medications such as Tacrolimus, Cyclosporine, Azathioprine, Mycophenolate Mofetil and Prednisone. These maintenance medications should not be listed as AR medications to treat acute rejection. When patients have a true acute rejection, they are given anti-rejection medication such as steroids, OKT3, ATG, Simulect and Zenapax, in addition to the maintenance medications. These are the medications that should be selected as anti-rejection.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind., Maint, or AR next to Other Immunosuppressive Medication field, and enter the full name of the medication in the space provided. Do not list non-immunosuppressive medications.
If the number of days is unavailable, select the appropriate status from the applicable Status field (N/A, Not Done, Missing, Unknown).(List of Status codes)
Drug Codes (List of Drug Codes)
Sandimmune (Cyclosporine A)
Neoral (CyA-NOF)
Prograf
(Tacrolimus, FK506)
Sirolimus (RAPA, Rapamycin,
Rapamune)
Leflunomide (LFL, Arava)
Azathioprine (AZA,
Imuran)
CellCept (Mycophenolate Mofetil, MMF)
Cyclophosphamide
(Cytoxan)
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex)
Atgam
(ATG)
OKT3 (Orthoclone, Muromonab)
Thymoglobulin
Zenapax
- Daclizumab
Simulect - Basiliximab
Gengraf (Abbott
Cyclosporine)
Everolimus (RAD, Certican)
EON (Generic
Cyclosporine)
Myfortic (Mycophenolate Sodium)
Other generic
Cyclosporine, specify brand:
Steroids (Prednisone,
Methylprednisolone, Solumedrol, Medrol,D ecadron)
Campath -
Alemtuzumab (anti-CD52)
FTY 720
Rituximab
Modified
Release Tacrolimus FK506E (MR4)
Generic Tacrolimus (Generic
Prograf)
Generic MMF (Generic CellCept)
Other
Immunosuppressive Medication, Specify
Other Immunosuppressive
Medication, Specify
| File Type | application/msword |
| File Title | TRR - Intestine |
| Author | pritchdh |
| Last Modified By | Darcy |
| File Modified | 2010-08-30 |
| File Created | 2010-08-30 |