Form 19 Kidney/Pancreas Registration

Records
Adult Kidney-Pancreas Transplant Recipient Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 08/31/2007
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI

B.

application. Currently in the worksheet, a red asterisk is
B.

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

j LIVING
k
l
m
n
Patient Status:

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

Retransplanted organ:

Primary Cause of Death:
Specify:

Contributory Cause of Death:

j Pancreas n
k
l
m
j Kidney n
k
l
m
n
j Kidney/Pancreas
k
l
m

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
to the transplant admission:

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

j IN INTENSIVE CARE UNIT
k
l
m
n
Medical Condition:

j HOSPITALIZED NOT IN ICU
k
l
m
n
j NOT HOSPITALIZED
k
l
m
n

Functional Status:

j No Limitations
k
l
m
n
j Limited Mobility
k
l
m
n
Physical Capacity:

j Wheelchair bound or more limited
k
l
m
n
j Not Applicable (< 1 year old or hospitalized)
k
l
m
n
j Unknown
k
l
m
n

Working for income:

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

If No, Not Working Due To:

j Working Full Time
k
l
m
n
j Working Part Time due to Demands of Treatment
k
l
m
n
j Working Part Time due to Disability
k
l
m
n
If Yes:

j Working Part Time due to Insurance Conflict
k
l
m
n
j Working Part Time due to Inability to Find Full Time Work
k
l
m
n
j Working Part Time due to Patient Choice
k
l
m
n
j Working Part Time Reason Unknown
k
l
m
n
j Working, Part Time vs. Full Time Unknown
k
l
m
n

j Within One Grade Level of Peers
k
l
m
n
Academic Progress:

j Delayed Grade Level
k
l
m
n

j Special Education
k
l
m
n
j Not Applicable < 5 years old
k
l
m
n
j Status Unknown
k
l
m
n

j Full academic load
k
l
m
n
j Reduced academic load
k
l
m
n
j Unable to participate in academics due to disease or condition
k
l
m
n

Academic Activity Level:

j Not Applicable < 5 years old/ High School graduate
k
l
m
n
j Status Unknown
k
l
m
n
Kidney Source of Payment:
Primary:
Specify:
Secondary:
Pancreas Source of Payment:
Primary:
Specify:
Secondary:

Clinical Information : PRETRANSPLANT
Height:

ft.

cm %ile ST=

in.

Weight:
BMI:

kg
kg/m2

%ile ST=
%ile

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 800978-4334 or by emailing [email protected].
Pretransplant Dialysis:

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

If Yes, Date First Dialyzed:

ST=

Average Daily Insulin Units:

ST=

Serum Creatinine at Time of Tx:

mg/dl

Viral Detection:

j Positive
k
l
m
n
HIV Serostatus:

j Negative
k
l
m
n

ST=

j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n
CMV IgG:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

CMV IgM:

j Negative
k
l
m
n

j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n
HBV Core Antibody:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

HBV Surface Antigen:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

HCV Serostatus:

j Negative
k
l
m
n
j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n
j Positive
k
l
m
n

EBV Serostatus:

j Negative
k
l
m
n

j Not Done
k
l
m
n
j UNK/Cannot Disclose
k
l
m
n

Was preimplantation kidney biopsy performed at the
transplant center:

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

Did patient receive any pretransplant blood
tranfusions:

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

Any tolerance induction technique used:

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

j NO PREVIOUS PREGNANCY
k
l
m
n

j 1 PREVIOUS PREGNANCY
k
l
m
n
j 2 PREVIOUS PREGNANCIES
k
l
m
n
j 3 PREVIOUS PREGNANCIES
k
l
m
n
Previous Pregnancies:

j 4 PREVIOUS PREGNANCIES
k
l
m
n
j 5 PREVIOUS PREGNANCIES
k
l
m
n
j MORE THAN 5 PREVIOUS PREGNANCIES
k
l
m
n
j NOT APPLICABLE: < 10 years old
k
l
m
n
j UNKNOWN
k
l
m
n

Malignancies between listing and transplant:

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

This question is NOT applicable for patients receiving living donor transplants who were never on the waiting list.

c Skin Melanoma
d
e
f
g
c Skin Non-Melanoma
d
e
f
g
c CNS Tumor
d
e
f
g
c Genitourinary
d
e
f
g
c Breast
d
e
f
g
If yes, specify type:

c Thyroid
d
e
f
g
c Tongue/Throat/Larynx
d
e
f
g
c Lung
d
e
f
g
c Leukemia/Lymphoma
d
e
f
g
c Liver
d
e
f
g

c Other, specify
d
e
f
g
Specify:

Clinical Information : TRANSPLANT PROCEDURE
Multiple Organ Recipient
Were extra vessels used in the transplant procedure:

Procedure Type:

Surgical Information:

j Before
k
l
m
n
Was the Pancreas revascularized before or after other
organs:

j Simultaneous
k
l
m
n

j After
k
l
m
n
j Not Applicable
k
l
m
n
j Iliac Fossa PA left/KI right
k
l
m
n
j Iliac Fossa PA right/KI left
k
l
m
n
Surgical Incision:

j Left
k
l
m
n
j Midline
k
l
m
n
j Right
k
l
m
n
j INTRA-PERITONEAL
k
l
m
n

Graft Placement:

j RETRO-PERITONEAL
k
l
m
n
j PARTIAL INTRA/RETRO-PERITONEAL
k
l
m
n
j Simultaneous Kidney-Pancreas
k
l
m
n

Operative Technique:

j Cluster
k
l
m
n
j Multi-Organ Non-Cluster
k
l
m
n
j ENTERIC W/ROUX-EN-Y
k
l
m
n
j ENTERIC W/O ROUX-EN-Y
k
l
m
n

Duct Management:

j CYSTOSTOMY
k
l
m
n
j DUCT INJECTION IMMEDIATE
k
l
m
n
j DUCT INJECTION DELAYED
k
l
m
n
j OTHER SPECIFY
k
l
m
n

Specify:

j SYSTEMIC SYSTEM (ILIAC:CAVA)
k
l
m
n
Venous Vascular Management:

j PORTAL SYSTEM (PORTAL OR TRIBUTARIES)
k
l
m
n
j NA/Multi-organ cluster
k
l
m
n
j CELIAC WITH PANCREAS
k
l
m
n
j Y-GRAFT TO SPA & SMA
k
l
m
n

Arterial Reconstruction:

j SPA TO SMA DIRECT
k
l
m
n
j SPA TO SMA WITH INTERPOSITION
k
l
m
n
j SPA ALONE
k
l
m
n
j OTHER SPECIFY
k
l
m
n

Specify:
Venous Extension Graft:

Kidney and Pancreas Preservation Information:

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

Total Cold ischemia Time Right KI(OR EN-BLOC): (if
pumped, 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, include
pump time):

hrs

ST=

Total Warm ischemia Time Left KI (Include
Anastomotic time):

min

ST=

Total Pancreas Preservation Time (include Cold,
Warm, Anastomotic time):

hrs

ST=

j Ice
k
l
m
n
Kidney(s) received on:

j Pump
k
l
m
n
j N/A
k
l
m
n

Received on ice:

j Stayed on ice
k
l
m
n

j Put on pump
k
l
m
n

Received on pump:

j Stayed on pump
k
l
m
n
j Put on ice
k
l
m
n

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:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m
j Oncocytoma
k
l
m
n
j Renal Cell Carcinoma
k
l
m
n

If yes, specify tumor type:

j Carcinoid
k
l
m
n
j Adenoma
k
l
m
n
j Transitional Cell Carcinoma
k
l
m
n
j Other Primary Kidney Tumor, Specify.
k
l
m
n

Specify:

Clinical Information : POST TRANSPLANT
Kidney Graft Status:

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

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:
Date Maintenance Dialysis Resumed:
Select a Dialysis Provider:

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

Provider #:
Provider Name:
Kidney Date of Graft Failure:

j HYPERACUTE REJECTION
k
l
m
n
j ACUTE REJECTION
k
l
m
n
j PRIMARY FAILURE
k
l
m
n
j GRAFT THROMBOSIS
k
l
m
n
Kidney Primary Cause of Graft Failure:

j INFECTION
k
l
m
n
j SURGICAL COMPLICATIONS
k
l
m
n
j UROLOGICAL COMPLICATIONS
k
l
m
n
j RECURRENT DISEASE
k
l
m
n
j OTHER SPECIFY CAUSE
k
l
m
n

Specify:
Contributory causes of graft failure:
Kidney Acute Rejection:

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

Kidney Graft Thrombosis:

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

Kidney Infection:

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

Surgical Complications:

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

Urological Complications:

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

Recurrent Disease:

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

Other, Specify:

j Yes, at least one episode treated with anti-rejection agent
k
l
m
n
Did patient have any acute kidney rejection episodes
between transplant and discharge:

j Yes, none treated with additional anti-rejection agent
k
l
m
n
j No
k
l
m
n
j Biopsy not done
k
l
m
n

Was biopsy done to confirm acute rejection:

j Yes, rejection confirmed
k
l
m
n
j Yes, rejection not confirmed
k
l
m
n

Most Recent Serum Creatinine Prior to Discharge:

mg/dl

Kidney Produced > 40ml of Urine in First 24 Hours:

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

Patient Need Dialysis within First Week:

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

ST=

Creatinine Decline by 25% or More in First 24 Hours
on 2 separate samples:

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

Pancreas Graft Status:

j Partial Function n
k
l
m
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.

c Insulin
d
e
f
g
Method of blood sugar control: (check all that
apply)

c Oral medication
d
e
f
g
c Diet
d
e
f
g
c No Treatment
d
e
f
g

Date Insulin/Medication Resumed:
Date of Graft Failure Pancreas:
Pancreas Graft Removed:

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

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:

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

Pancreas Infection:

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

Bleeding:

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

Anastomotic Leak:

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

Hyperacute Rejection:

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

Pancreas Acute Rejection:

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

Biopsy Proven Isletitis:

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

Pancreatitis:

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

Other, Specify:

j Yes, at least one episode treated with anti-rejection agent
k
l
m
n
Did patient have any acute pancreas rejection
episodes between transplant and discharge:

j Yes, none treated with additional anti-rejection agent
k
l
m
n
j No
k
l
m
n
j Biopsy not done
k
l
m
n

Was biopsy done to confirm acute rejection:

j Yes, rejection confirmed
k
l
m
n

j Yes, rejection not confirmed
k
l
m
n

Pancreas Transplant Complications:
(Not leading to graft failure.)
Pancreatitis:

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

Anastomotic Leak:

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

Abcess or Local Infection:

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

Other:

Weight Post Transplant:

lbs.

kg

ST=

Treatment
Biological or Anti-viral Therapy:

j Unknown/Cannot disclose
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
c Acyclovir (Zovirax)
d
e
f
g
c Cytogam (CMV)
d
e
f
g
c Gamimune
d
e
f
g
c Gammagard
d
e
f
g
c Ganciclovir (Cytovene)
d
e
f
g

If Yes, check all that apply:

c Valgancyclovir (Valcyte)
d
e
f
g
c HBIG (Hepatitis B Immune Globulin)
d
e
f
g
c Flu Vaccine (Influenza Virus)
d
e
f
g
c Lamivudine (Epivir) (for treatment of Hepatitis B)
d
e
f
g
c Other, Specify
d
e
f
g

c Valacyclovir (Valtrex)
d
e
f
g
Specify:
Specify:

Other therapies:

j YES n
k
l
m
n
j NO
k
l
m
c Photopheresis
d
e
f
g

If Yes, check all that apply:

c Plasmapheresis
d
e
f
g
c Total Lymphoid Irradiation (TLI)
d
e
f
g

Immunosuppressive Information
Are any medications given currently for maintenance
or anti-rejection:

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

Did the patient participate in any clinical research
protocol for immunosuppressive medications:

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

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
associated box(es) 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, 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 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 (example: 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.
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.

Ind. Days
Steroids
(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron)

c
d
e
f
g

Atgam (ATG)

c
d
e
f
g

OKT3 (Orthoclone, Muromonab)

c
d
e
f
g

Thymoglobulin

c
d
e
f
g

Simulect - Basiliximab

c
d
e
f
g

Zenapax - Daclizumab

c
d
e
f
g

Azathioprine (AZA, Imuran)

c
d
e
f
g

EON (Generic Cyclosporine)

c
d
e
f
g

Gengraf (Abbott Cyclosporine)

c
d
e
f
g

Other generic Cyclosporine, specify brand:

c
d
e
f
g

ST

Neoral (CyA-NOF)

c
d
e
f
g

Sandimmune (Cyclosporine A)

c
d
e
f
g

Mycophenolate Mofetil (MMF, Cellcept, RS61443)

c
d
e
f
g

Tacrolimus (Prograf, FK506)

c
d
e
f
g

Modified Release Tacrolimus FK506E (MR4)

c
d
e
f
g

Sirolimus (RAPA, Rapamycin, Rapamune)

c
d
e
f
g

Myfortic (Mycophenolate Sodium)

c
d
e
f
g

Other Immunosuppressive Medications
Ind. Days

ST

Maint AR

Campath - Alemtuzumab (anti-CD52)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Cyclophosphamide (Cytoxan)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Leflunomide (LFL, Arava)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Methotrexate (Folex, PFS, Mexate-AQ,
Rheumatrex)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Other Immunosuppressive Medication, Specify

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Other Immunosuppressive Medication, Specify

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Rituximab

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Investigational Immunosuppressive Medications
Ind.

Days

ST

Maint AR

Everolimus (RAD, Certican)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

FTY 720

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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