17b Liver Adult Transplant Recipient Follow Up Worksheet

Records
Adult Liver Transplant Recipient Follow-Up Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 10/31/2010
®

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

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

If No, 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

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

If Yes:

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/ High School graduate or GED
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 or GED
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

ST=

kg

ST=

kg/m2

BMI:

Pathology confirmed liver diagnosis at hospital
discharge:
Specify:

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

Denovo Hepatitis

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

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

Patient Noncompliance:

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

Other, Specify:

Discharge Lab Data:
Lab Date:
Total Bilirubin:

mg/dl

ST=

SGPT/ALT:

U/L

ST=

Serum Albumin:

g/dl

ST=

Serum Creatinine:

mg/dl

ST=

INR (ratio):

ST=

Most Recent Lab Data:
Lab Date:
Total Bilirubin:

mg/dl

ST=

SGPT/ALT:

U/L

ST=

Serum Albumin:

g/dl

ST=

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:
Previous Validated Maintenance Follow-Up
Medications:

j Yes, same as validated TRR form
k
l
m
n
Were any medications given during the followup period for maintenance:

j Yes, same as previous validated report
k
l
m
n
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

CellCept (Mycophenolate Mofetil; MMF)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Generic MMF (Generic CellCept)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Prograf (Tacrolimus, FK506)

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Generic Tacrolimus (Generic Prograf)

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

Curr 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

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

Other Immunosuppressive Medication, Specify

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

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