17c Liver Pediatric Post 5 Year Transplant Recipient Follow

Records
Pediatric Liver Transplant Recipient Post 5-Year Follow-Up Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2011
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI ® application. Currently in the
worksheet, a red asterisk is 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:

Previous FollowUp:

Previous Px Stat
Date:

Transplant Recipient Registration

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

LIVING
Patient Status:

DEAD
RETRANSPLANTED

Primary Cause of Death:

Specify:

Functional Status:

Definite Cognitive delay/impairment
Probable Cognitive delay/impairment
Cognitive Development:

Questionable Cognitive delay/impairment
No Cognitive delay/impairment
Not Assessed

Definite Motor delay/impairment
Probable Motor delay/impairment
Motor Development:

Questionable Motor delay/impairment
No Motor delay/impairment
Not Assessed

Clinical Information

Date of Measurement:
Height:

ft.

Weight:
BMI:

Graft Status:

in.

lbs.

cm

ST=

kg

ST=

2

kg/m

Functioning

Failed

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

Vascular Thrombosis

Hepatic arterial thrombosis:

Hepatic outflow obstruction:

Portal vein thrombosis:

Biliary Tract Complication:

Denovo Hepatitis

Recurrent Hepatitis:

Recurrent Disease:

Acute Rejection:

Chronic Rejection:

Infection:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

Other, Specify:

Most Recent Serum Creatinine:

Diabetes onset during the follow-up period:

Insulin dependent:

mg/dl

ST=

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

Coronary Artery Disease Since Last Follow Up:

Post Transplant Malignancy:

Donor Related:

Recurrence of Pre-Tx Tumor:

De Novo Solid Tumor:
De Novo Lymphoproliferative disease and
Lymphoma:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK