Form 23 Pancreas Follow-up

Records
Adult Pancreas 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:

Physician Name:
NPI:

j Transplant Center
k
l
m
n
Follow-up Care Provided By:

j Non Transplant Center Specialty Physician
k
l
m
n
j Primary Care Physician
k
l
m
n
j Other Specify
k
l
m
n

Specify:

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:

Contributory Cause of Death:
Specify:

Contributory Cause of Death:
Specify:

Hospitalizations:
Has the patient been hospitalized since the last patient status date:

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

Number of Hospitalizations:

St=

Noncompliance:
Was there evidence of noncompliance with immunosuppression
medication during this follow-up period that compromised the patient's
recovery:

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

Functional Status:

j No Limitations
k
l
m
n
Physical Capacity:

j Limited Mobility
k
l
m
n
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

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

Working for income:
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
j Working Part Time due to Insurance Conflict
k
l
m
n

If Yes:

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
j Delayed Grade Level
k
l
m
n
j Special Education
k
l
m
n

Academic Progress:

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

Primary Insurance at Follow-up:
Specify:

Clinical Information
Height:

ft.

Weight:

lbs.

in.

cm

%ile

St=

kg

%ile

St=

kg/m2

BMI:

Graft Status:

%ile

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.

c Insulin
d
e
f
g
Method of blood sugar control:

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 Failure:
Pancreas Graft Removed:

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

Date Pancreas Removed:
Primary Cause of Graft Failure:
Other, Specify:
Contributory causes of graft failure:
Graft/Vascular Thrombosis:

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

Bleeding:

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

Anastomotic Leak:

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

Biopsy Proven Isletitis:

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

Pancreatitis:

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

Patient Noncompliance

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

Other, Specify:

Conv. From Bladder to Enteric Drain Performed:

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

If Yes, Enteric Drainage Date:

Serum Amylase:

u/L

St=

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

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

Anastomotic Leak:

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

Abcess or Local Infection:

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

Other Complications:

j Yes, at least one episode treated with anti-rejection agent
k
l
m
n
Did patient have any acute rejection episodes during the follow-up
period:

j Yes, none treated with additional anti-rejection agent
k
l
m
n
j No
k
l
m
n
j Unknown
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
j Unknown
k
l
m
n

Postransplant Malignancy:

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

Treatment
Biological or Anti-viral therapy:

j YES n
k
l
m
n
j NO n
k
l
m
j Unknown/Cannot disclose
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 Valacyclovir (Valtrex)
d
e
f
g
c Other, Specify
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
Previous Validated Maintenance Follow-Up Medications:

j Yes, same as previous validated report
k
l
m
n
Were any medications given during the follow-up period for maintenance:

j Yes, but different than previous validated report
k
l
m
n
j None given
k
l
m
n

Did the physician discontinue all maintenance immunosuppressive
medications:

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

Specify:

Immunosuppressive Medications
View Immunosuppressive Medications
Definitions Of Immunosuppressive Follow-Up Medications

For each of the immunosuppressant medications listed, check Previous Maintenance (Prev Maint), Current Maintenance (Curr Maint) or Anti-rejection (AR) to indicate all medications that were
prescribed for the recipient during this follow-up period, and for what reason. If a medication was not given, leave the associated box(es) blank.
Previous Maintenance (Prev Maint) includes all immunosuppressive medications given during the report period, which covers the period from the last clinic visit to the current clinic visit, 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.
Current Maintenance (Curr Maint) includes all immunosuppressive medications given at the current clinic visit to begin in the next report 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.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode since the last clinic visit (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: The Anti-rejection field refers to any anti-rejection medications since the last clinic visit, not just at the time of the current clinic visit.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Previous Maint, or Current 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.

Prev Maint

Curr Maint

AR

Steroids (Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Atgam (ATG)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

OKT3 (Orthoclone, Muromonab)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Thymoglobulin

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Simulect - Basiliximab

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Zenapax - Daclizumab

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Azathioprine (AZA, Imuran)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

EON (Generic Cyclosporine)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Gengraf (Abbott Cyclosporine)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Other generic Cyclosporine, specify brand:

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Neoral (CyA-NOF)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Sandimmune (Cyclosporine A)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Mycophenolate Mofetil (MMF, Cellcept, RS61443)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Tacrolimus (Prograf, FK506)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Modified Release Tacrolimus FK506E (MR4)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Sirolimus (RAPA, Rapamycin, Rapamune)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Myfortic (Mycophenolate Sodium)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Other Immunosuppressive Medications
Prev Maint
Campath - Alemtuzumab (anti-CD52)

c
d
e
f
g

Curr Maint

c
d
e
f
g

AR

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
Prev Maint

Curr 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

UNOS View Only
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