11e Post 5-Year Thoracic Follow-up

Records
Post 5 Year Adult 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
Patient Status:

j DEAD
k
l
m
n
j RETRANSPLANTED
k
l
m
n

Primary Cause of Death:
Specify:

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:

mg/dl

St=

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.
Kidney Date of Failure:
Kidney Primary Cause of Graft Failure:
Primary Other, Specify:
If Functioning, Most Recent Serum Creatinine:

Pancreas Graft Status:

mg/dl

St=

j Functioning n
k
l
m
n
j Partial Function n
k
l
m
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.
Pancreas Date of Failure:
Pancreas 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:

Pancreas Clinical Information
Graft Status:

j Functioning n
k
l
m
n
j Partial Function n
k
l
m
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:
Contributory Cause 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:

mg/dl

St=

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 Failure:
Other, Specify:
Most Recent Serum Creatinine:

mg/dl

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

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

St=

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:

Postransplant Malignancy:

mg/dl

St=

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

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.
Date of Failure:

j Primary Non-Function
k
l
m
n
Primary Cause of Graft Failure:

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

Other, Specify:

Coronary Artery Disease? (Heart Only)

j Yes n
k
l
m
n
j No n
k
l
m
j UNK
k
l
m
j NO BOS
k
l
m
n
j Yes, Grade OP
k
l
m
n
j Yes, Grade 1
k
l
m
n

Bronchiolitis Obliterans Syndrome (Lung Only):

j Yes, Grade 2
k
l
m
n
j Yes, Grade 3
k
l
m
n
j Yes, Grade UNK
k
l
m
n
j Unknown
k
l
m
n

Renal Dysfunction?

j Yes n
k
l
m
n
j No n
k
l
m
j UNK
k
l
m

If Yes, Creatinine > 2.5 mg/dl?

j Yes n
k
l
m
n
j No n
k
l
m
j UNK
k
l
m

Chronic Dialysis?

j Yes n
k
l
m
n
j No n
k
l
m
j UNK
k
l
m

Renal Tx Since Thoracic Tx?

j Yes n
k
l
m
n
j No n
k
l
m
j UNK
k
l
m

Most Recent Serum Creatinine:

mg/dl

St=