Form 2 Living Donor Registration

Living Donor Registration (LDR) Record Field Descriptions

Living Donor Registration (LDR) records are generated as soon as the Living Donor Feedback process is completed by the Transplant Center. The LDR record is completed for all living organ donors. This includes kidney, segmental liver, heart, single lung, lung lobe, sectional pancreas, sectional intestine and domino whole liver donors.

Complete the LDR record at hospital discharge or six weeks post donation, whichever is first.

Note: If the procedure was aborted, and the organ was not recovered, you are only required to complete the Donor, Pre-Donation Clinical and Surgical Information sections below.

The LDR record must be completed within 60 days from the record generation date. See OPTN Policy for additional information. Use the search feature to locate specific policy information on Data Submission Requirements.

To correct information that is already displayed in an electronic record, call the UNet^SM Help Desk at 1-800-978-4334.

Provider Information

Recipient Center: The Recipient Center information reported in the Living Donor Feedback in TIEDI^® will display. Verify that the displayed transplant center is the hospital where the transplant operation was performed. The provider number printed in the record is the 6-character Medicare identification number of the hospital.

Donor Information

Donor Name: Verify the last name and first name of the living donor are correct. If the information is incorrect, corrections may be made to the Living Donor Feedback record.

UNOS Donor ID#: Each living donor is assigned a unique donor identification number when the donor information is entered into the Living Donor Feedback record. For more information about Donor IDs, see Donor ID Information.

Note: For U.S. residents, complete their Address, Home City, State, Zip Code, and Home and Work Phone numbers.

For non-U.S. residents, complete their Address, Home City, and Home and Work Phone numbers.

Address: Enter the street address where the donor lived before hospitalization for recovery of this organ. This field is required.

Home City: Enter the name of the city where the donor lived before hospitalization for recovery of this organ. If the donor is a non-U.S. resident, enter the city and country of residence. This field is required.

State: Select the name of the state where the donor's home city is located. (List of State codes – See Appendix A) In the event the donor is a non-U.S. resident, this field should be left blank.

Zip Code: Enter the U.S. Postal Zip Code of the location where the donor lived before hospitalization for recovery of this organ. In the event the donor is a non-U.S. resident, this field may be left blank.

Home Phone: Enter the donor's home phone number. This field is required.

Work Phone: Enter the donor's work phone number.

Email: Enter the donor's e-mail address.

SSN: Enter the donor's social security number. This field is required.

Note: SSN cannot:
Contain 00 in the 4th and 5th place (e.g. XXX-00-XXXX is invalid)
Contain 0000 in the last 4 places (e.g. XXX-XX-0000 is invalid)
Begin with 666

Note: If a living donor does not have a social security number, contact the Organ Center at 1-800-292-9537 for a 9FN or 9CH number.

Date of Birth: Enter the date the donor was born using the standard 8-digit numeric format of MM/DD/YYYY. This field is required.

Gender: Select the appropriate choice to indicate if the donor is male or female. This field is required.

Marital Status at time of Donation: Select the donor's marital status from the drop-down list. This field is required.

Single
Married
Divorced
Separated
Life Partner
Widowed
Unknown

ABO Blood Group: The donor’s blood type reported in the Living Donor Feedback in TIEDI will display.

O
A
B
AB
A1
A2
A1B
A2B

Donor Type: Select the relationship of the living donor to the recipient from the drop-down list. This field is required.

Biological, blood related Parent - including blood related mother, blood related father

Biological, blood related Child - including blood related son, blood related daughter (NOT adopted child, NOT step-child)

Biological, blood related Identical Twin - including blood related brothers, blood related sister

Biological, blood related Full Sibling - including blood-related sister or blood related brother with whom donor shares both parents

Biological, blood related Half Sibling - including blood-related sister or blood related brother with whom donor shares one parent

Biological, blood related Other Relative: Specify - including blood related aunt, uncle, grandparent, grandchild, cousin, niece, nephew (NOT those related to you "by marriage"). Specify relationship to the recipient in the space provided.

Non-Biological, Spouse: including husband, wife

Non-Biological, Life Partner - refers to a non-married, long-term partner of either gender

Non-Biological, Unrelated: Paired Donation - The donation and receipt of human kidneys under the following circumstances:

• An individual (the first living donor) desires to make a living donation of a kidney specifically to a particular patient (the first patient), but the first living donor is biologically incompatible as a donor for the first patient.

• A second individual (the second living donor) desires to make a living donation of a kidney specifically to a second particular patient (the second patient), but the second living donor is biologically incompatible as a donor for the second patient.

•  The first living donor is biologically compatible as a donor of a kidney for the second patient, and the second living donor is biologically compatible as a donor of a kidney for the first patient. If there is any additional donor-patient pair as described above, each living donor in the group of donor-patient pairs is biologically compatible as a living donor of a kidney for a patient in the group.

•  All donors and patients in the group of donor-patient pairs enter into a single agreement to donate and receive the kidneys, respectively, according to biological compatibility within the group.

•  Other than described as above, no valuable consideration is knowingly acquired, received, or otherwise transferred for the donation of the kidneys.

Non-Biological, Unrelated: Non-Directed Donation (Anonymous) - altruistic donor, stranger, anonymous donor, Good Samaritan donor

Non-Biological, Living/Deceased Donation - occurs when a non-matching relative or friend donates a kidney to the general waiting list pool, then the relative or friend of the living donor has priority on the waiting list for a deceased kidney. (One living transplant; one deceased transplant)

Non-Biological, Unrelated Domino - occurs when an unrelated living donor receives a heart or whole liver transplant, then donates their heart or liver to an unrelated heart or whole liver candidate.

Non-Biological, Other Unrelated Directed Donation: Specify - including adopted child, adopted parent or grandparent, any relative by adoption, friend, co-worker, in-law, god-children, god-parents, relative by marriage, anyone NOT blood-related and NOT your spouse. Specify in the space provided.

Ethnicity/Race: Select all origins that indicate the donor’s ethnicity/race. This field is required.

American Indian or Alaska Native: Select for donors who are of North, South, or Central American descent (e.g., American Indian, Eskimo, Aleutian, Alaska Indian). If the donor belongs to the primary category, but does not belong to any of the subcategories listed, select American Indian or Alaska Native: Other. If unknown, select American Indian or Alaska Native: Not Specified/Unknown.

Asian: Select for donors who are of Asian descent (e.g., Asian Indian/Indian Sub-Continent, Chinese, Filipino, Japanese, Korean, Vietnamese). If the donor belongs to the primary category, but does not belong to any of the subcategories listed, select Asian: Other. If unknown, select Asian: Not Specified/Unknown.

Black or African American: Select for donors of African descent (e.g., African American, African (Continental), West Indian, Haitian). If the donor belongs to the primary category, but does not belong to any of the subcategories listed, select Black or African American: Other. If unknown, select Black or African American: Not Specified/Unknown.

Hispanic/Latino: Select for donors who are of Central or South American descent (e.g., Mexican, Puerto Rican (Mainland), Puerto Rican (Island), Cuban). If the donor belongs to the primary category, but does not belong to any of the subcategories listed, select Hispanic/Latino: Other. If unknown, select Hispanic/Latino: Not Specified/Unknown.

Native Hawaiian or Other Pacific Islander: Select for donors who are descendants of the Native Hawaiian, Guamanian or Chamorro, or Samoan peoples. If the donor belongs to the primary category, but does not belong to any of the subcategories listed, select Native Hawaiian or Other Pacific Islander: Other. If unknown, select Native Hawaiian or Other Pacific Islander: Not Specified/Unknown.

White: Select for donors who are of European Descent, Arab or Middle Eastern or North African (non-Black). If the donor belongs to the primary category, but does not belong to any of the subcategories listed, select White: Other. If unknown, select White: Not Specified/Unknown.

Citizenship: Select as appropriate to indicate the donor's citizenship. This field is required.

U.S. Citizen:  A United States citizen by birth or naturalization.

Non-U.S. Citizen/U.S. Resident: A non-citizen of the United States for whom the United States is the primary place of residence.

Non-U.S. Citizen/Non-U.S. Resident, Traveled to U.S. for Reason Other Than Transplant: A non-citizen of the United States for whom the United States is not the primary place of residence, and who came to the U.S. for a reason other than transplant.

Non-U.S. Citizen/Non-U.S. Resident, Traveled to U.S. for Transplant: A non-citizen of the United States for whom the United States is not the primary place of residence, and who came to the U.S. for the purpose of transplant.

Year of Entry to the U.S.: If the donor is a Non-U.S. Citizen/Non-U.S. Resident, enter the year the donor entered the United States. This field is required.

Country of Permanent Residence (List of Countries – Appendix B) – The country where the donor’s primary place of residence is located.

Highest Education Level: Select the choice that best describes the living donor's highest level of education. This field is required.

None
Grade School (0-8)
High School (9-12) or GED
Attended College/Technical School
Associate/Bachelor Degree
Post-College Graduate Degree
N/A (< 5 Yrs Old)
Unknown

Did the donor have health insurance: If the donor had health insurance at the time of donation, select Yes. If not, select No. If unknown, select UNK. This field is required.

Functional Status: Select the choice that best describes the donor's functional status just prior to the time of donation. This field is required.

Note: The Karnofsky Index will display for adult donors aged 18 and older.

100% - Normal, no complaints, no evidence of disease
90% - Able to carry on normal activity: minor symptoms of disease
80% - Normal activity with effort: some symptoms of disease
70% - Cares for self: unable to carry on normal activity or active work
60% - Requires occasional assistance but is able to care for needs
50% - Requires considerable assistance and frequent medical care
40% - Disabled: requires special care and assistance
30% - Severely disabled: hospitalization is indicated, death not imminent
20% - Very sick, hospitalization necessary: active treatment necessary
10% - Moribund, fatal processes progressing rapidly
Unknown

Note: The Lansky Scale will display for pediatric donors aged 1 to 17.

100% - Fully active, normal
90% - Minor restrictions in physically strenuous activity
80% - Active, but tires more quickly
70% - Both greater restriction of and less time spent in play activity
60% - Up and around, but minimal active play; keeps busy with quieter activities
50% - Can dress but lies around much of day; no active play; can take part in quiet play/activities
40% - Mostly in bed; participates in quiet activities
30% - In bed; needs assistance even for quiet play
20% - Often sleeping; play entirely limited to very passive activities
10% - No play; does not get out of bed
Not Applicable (patient < 1 year old)
Unknown

Physical Capacity (check one): Select the choice that best describes the donor's physical capacity just prior to the time of donation. This field is required.

No Limitations
Limited Mobility
Wheelchair bound or more limited
Unknown

Physical Capacity is the ability to perform bodily activities such as walking, dressing, bathing, grooming, etc.

Working for income: (Complete for donors 19 years of age or older.) If the donor was working for income just prior to the time of donation, select Yes. If not, select No. If unknown, select UNK. (This field is required.

If Yes: If Yes is selected, select the donor's working status from the drop-down list.

Working Full Time
Working Part Time due to Disability
Working Part Time due to Insurance Conflict
Working Part Time due to Inability to Find Full Time Work
Working Part Time due to Donor Choice
Working Part Time Reason Unknown
Working, Part Time vs. Full Time Unknown

If No, Not Working Due To: If No is selected, select the reason from the drop-down list.

Disability - A physical or mental impairment that interferes with or prevents a donor from working (e.g. arthritis, mental retardation, cerebral palsy, etc.).
Insurance Conflict - Any differences between a donor and insurance company that prevent them from working.
Inability to Find Work - The lack of one's ability to find work (e.g. lack of transportation, work experience, over qualification, unavailable work, etc.).
Donor Choice - Homemaker - A donor who chooses to manage their own household instead of performing work for pay.
Donor Choice - Student Full Time/Part Time - A donor who is enrolled in and/or participating in college.
Donor Choice - Retired - A donor who no longer has an active working life such as an occupation, business or office job.
Donor Choice - Other - Any reason not listed above that would prevent a donor from working.
Unknown
 

Pre-Donation Clinical Information

Viral Detection:

Have any of the following viruses ever been tested for: Indicate whether the donor was tested for HIV, CMV, HBV, HCV or EBV prior to the donation by selecting Yes or No. This field is required.

If Yes is selected, indicate which viruses the donor was tested for prior to donation.

HIV (Human Immunodeficiency Virus) - Any of several retroviruses and especially HIV-1 that infect and destroy helper T cells of the immune system causing the marked reduction in their numbers that is diagnostic of AIDS. If Yes is selected, complete the following field:

HIV Status: Select the result of the test (Positive, Negative, Not Done, UNK/Cannot Disclose).

CMV (Cytomegalovirus) - A herpes virus (genus Cytomegalovirus) that causes cellular enlargement and formation of eosinophilic inclusion bodies especially in the nucleus and that acts as an opportunistic infectious agent in immunosuppressed conditions (as AIDS). If Yes is selected, complete the following fields:

CMV Total: Select the result of the test (Positive, Negative, Not Done, UNK/Cannot Disclose).IgG: Select the result of the test.
IgM: Select the result of the test.
Nucleic Acid Testing: Select the result of the test.

HBV (Hepatitis B Virus) - A sometimes fatal hepatitis caused by a double-stranded DNA virus (genus Orthohepadnavirus of the family Hepadnaviridae) that tends to persist in the blood serum and is transmitted especially by contact with infected blood (as by transfusion or by sharing contaminated needles in illicit intravenous drug use) or by contact with other infected bodily fluids (as during sexual intercourse) -- also called serum hepatitis. If Yes is selected, complete the following fields:

Core Antibody: Select the result of the test.
Surface Antigen: Select the result of the test.
HBV DNA (NAT/PCR): Select the result of the test.

HCV (Hepatitis C Virus) - A disease caused by a flavivirus that is usually transmitted by parenteral means (as injection of an illicit drug, blood transfusion, or exposure to blood or blood products) and that accounts for most cases of non-A, non-B hepatitis. If Yes is selected, complete the following fields:

Antibody: Select the result of the test.
RIBA: Select the result of the test.
HCV RNA (NAT/PCR): Select the result of the test.

EBV (Epstein-Barr Virus) - A herpesvirus (genus Lymphocryptovirus) that causes infectious mononucleosis and is associated with Burkitt's lymphoma and nasopharyngeal carcinoma -- abbreviation EBV; called also EB virus. If Yes is selected, complete the following fields:

EBV Total: Select the result of the test (Positive, Negative, Not Done, UNK/Cannot Disclose).
IgG: Select the result of the test.
IgM: Select the result of the test.

Pre-Donation Height and Weight

Height: Enter the height of the living donor prior to donation in the appropriate space, in feet and inches or centimeters. If the living donor's height is not available, select the appropriate (ST) drop-down list (Missing, Unknown, N/A, Not Done). This field is required.

Weight: Enter the weight of the living donor prior to donation in the appropriate space, in pounds or kilograms. If the living donor's weight is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done). This field is required.

History of Cancer: Indicate whether the donor had a history of cancer prior to the donation. If the donor had a history of cancer, select the type of cancer. If not, select No. This field is required. If the type of cancer is not listed, select the Other, specify and enter the name of the cancer in the Specify field. If the type of cancer is unknown, select Unknown.

No
Skin - Squamous, Basal Cell
Skin - Melanoma
CNS Tumor - Astrocytoma
CNS Tumor - Glioblastoma Multiforme
CNS Tumor - Medulloblastoma
CNS Tumor - Neuroblastoma
CNS Tumor - Angioblastoma
CNS Tumor - Meningioma
CNS Tumor - Other
Genitourinary - Bladder
Genitourinary - Uterine Cervix
Genitourinary - Uterine Body Endometrial
Genitourinary - Uterine Body Choriocarcinoma
Genitourinary - Vulva
Genitourinary - Ovarian
Genitourinary - Penis, Testicular
Genitourinary - Prostate
Genitourinary - Kidney
Genitourinary - Unknown
Gastrointestinal - Esophageal
Gastrointestinal - Stomach
Gastrointestinal - Small Intestine
Gastrointestinal - Colo-Rectal
Gastrointestinal - Liver & Biliary Tract
Gastrointestinal - Pancreas
Breast
Thyroid
Tongue/Throat
Larynx
Lung (Include Bronchial)
Leukemia/Lymphoma
Unknown
Other, Specify

Cancer Free Interval: If the donor had a history of cancer prior to donation, enter the number of the years the donor was free of the cancer. Cancer-free interval can be entered in portions of a year by entering a decimal. If the number of years in unknown, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).This field is required.

History of Cigarette Use: If the donor has a history of cigarette use, select Yes. If not, select No. This field is required.

If Yes, Check # of pack years is the number of packs of cigarettes the donor smoked per day multiplied by the number of years. For example, a donor smoking 2 packs of cigarettes per day for 10 years would equal 20 pack years.

0-10
11-20
21-30
31-40
41-50
>50
Unknown pack years

Duration of Abstinence: Select the number of months the donor has abstained from cigarettes. If the time is unknown, select Unknown duration. If the donor has not stopped smoking, select Continues To Smoke.

0-2 months
3-12 months
13-24 months
25-36 months
37-48 months
49-60 months
>60 months
Continues to Smoke
Unknown duration

Other Tobacco Used: If the donor has a history of other tobacco use, select Yes. If not, select No. If unknown, select UNK. This field is required.

This section displays if a kidney or lung was recovered from the donor.

Diabetes: If the donor had diabetes prior to the donation, select Yes. If not, select No. If unknown, select UNK. (This is a required field.)

If Yes is selected, Treatment: Select the type of treatment from the drop-down list.

Insulin
Oral Hypoglycemic Agent
Diet

Pre-Donation Liver Clinical Information

This section displays if a liver was recovered from the donor or the procedure was aborted.

Total Bilirubin: Enter the most recent lab value prior to donation for total serum bilirubin in mg/dl. This field is required. If any of the data values are unavailable, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

SGOT/AST: Enter the most recent lab value prior to donation for the serum glutamic oxaloacetic transaminase or aspartate transaminase in U/L. (This is a required field.) If any of the data values are unavailable, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

SGPT/ALT: Enter the most recent lab value prior to donation for the Serum Glutamic Pyruvic Transaminase/Alanine Aminotransferase in U/L. (This is a required field.) If any of the data values are unavailable, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Alkaline Phosphatase: Enter the most recent lab value prior to donation for the serum alkaline phosphatase value in units/L. (This is a required field.) If any of the data values are unavailable, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Serum Albumin: Enter the most recent lab value prior to donation for the serum albumin value in g/dl. (This is a required field.) If any of the data values are unavailable, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done.

Serum Creatinine: Enter the most recent lab value prior to donation for the serum creatinine value in mg/dl. (This is a required field.) If any of the data values are unavailable, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

INR: International Normalized Ratio. Enter the most recent prior to donation ratio of the prothrombin time (in seconds) to the control prothrombin time (in seconds). (This is a required field.) If any of the data values are unavailable, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Liver Biopsy: If the donor had a liver biopsy prior to donation, select Yes. If not, select No. This field is required.

If Yes is selected, % Macrovesicular fat: Enter the percentage of macro vesicular fat. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Macrovesicular type - Large fat droplets balloon the liver cell, displacing the nucleus to the periphery of the cell, like an adipocyte. Triglyceride accumulates most commonly because it has the highest turnover rate of all hepatic fatty acid esters. Liver uptake of FFA from adipose tissue and the diet is unrestrained, whereas FFA disposition by oxidation, esterification, and VLDL secretion is limited.

If Yes is selected, % Micro/intermediate vesicular fat: Enter the percentage of micro/intermediate vesicular fat. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Microvesicular - Fatty liver, small fat droplets accumulate, cells appear foamy, and nuclei are central. Triglycerides collect in subcellular organelles (i.e. endoplasmic reticulum), reflecting widespread metabolic disturbance. Mitochondrial injury limits FFA oxidation, while apoprotein synthesis necessary for VLDL secretion is depressed, leading to triglyceride accumulation.

Pre-Donation Kidney Clinical Information

This section displays if a kidney was recovered from the donor or the procedure was aborted.

History of Hypertension: If the donor had a history of hypertension prior to donation, select Yes and the duration from the drop-down list. If not, select No. If unknown, select Unknown. This field is required.

No
Yes, 0 - 5 Years
Yes, 6 - 10 Years
Yes, > 10 Years
Yes, Unknown Duration
Unknown

If Yes, Method of Control: If the donor had a history of hypertension, indicate whether the method of control was by selecting Yes, No or UNK for the following methods.

Diet
Diuretics
Other Hypertension Medication

Donor Kidney Discharge Creatinine//Serum Creatinine: Enter the lab value for the kidney donor's serum creatinine value in mg/dl taken prior to donation. This is a required field. If the value is not available, select the appropriate (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Preoperative Blood Pressure Systolic: Enter the living donor's systolic blood pressure. (This is a required field.) If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Preoperative Blood Pressure Diastolic: Enter the donor's diastolic blood pressure. (This is a required field.) If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Urinalysis: Enter the donor's Urine Protein or Protein-Creatinine Ratio. This field is required.

If Urine Protein is selected, select the result from the drop-down list.

Positive
Negative
Unknown
Not Done

Pre-Donation Lung Clinical Information

This section displays if a lung was recovered from the donor or the procedure was aborted.

FVC% predicted (Before Bronchodilators and After Bronchodilators): Enter the donor's FVC% predicted value before bronchodilators and FVC% predicted value after bronchodilators. (This is a required field.) If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

FEV 1% predicted (Before Bronchodilators and After Bronchodilators): Enter the donor's FEV 1% predicted value before bronchodilators and FEV 1% predicted value after bronchodilators. (This is a required field.) If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

FEF (25-75%)% predicted (Before Bronchodilators and After Bronchodilators): Enter the donor's FEF (25-75%)% predicted value before bronchodilators and FEF (25-75%)% predicted value after bronchodilators. (This is a required field.) If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

TLC % predicted (Before Bronchodilators and After Bronchodilators): Enter the donor's TLC% predicted value before bronchodilators and TLC% predicted value after bronchodilators. (This is a required field.) If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Diffusing lung capacity corrected for alveolar volume % predicted: Enter the % predicted value. This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Pa0₂ on room air: Enter the value for Pa0₂ on room air for the donor in mm/Hg. This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Liver Surgical Information

This section displays if a liver was recovered from the donor or the procedure was aborted.

Type of Transplant Graft: Select the type of transplant graft from the drop-down list. This field is required.

Left Lateral Segment (Peds)

Left Lobe Without Middle Hepatic Vein (MHV)
Left Lobe With Middle Hepatic Vein (MHV)

Right Lobe Without Middle Hepatic Vein (MHV)
Right Lobe With Middle Hepatic Vein (MHV)
Domino Whole Liver

Domino Partial Liver

Kidney Surgical Information

This section displays if a kidney was recovered from the donor or the procedure was aborted.

Type of Transplant Graft: The type of transplant will display from the Living Donor Feedback.

Left Kidney
Right Kidney
Hem-Renal

Intended Procedure Type: Select the procedure type from the drop-down list. This field is required.

Transabdominal
Flank (retroperitoneal)
Laparoscopic Not Hand-Assisted
Laparoscopic Hand-Assisted

Natural Orifice

Conversion from Laparoscopic to Open: If Laparoscopic was selected for Intended Procedure Type, and there was a conversion from laparoscopic to open procedure, select Yes. If there wasn’t a conversion, select No.

Lung Surgical Information

This section displays if a lung was recovered from the donor or the procedure was aborted.

Type of Transplant Graft: The type of transplant (Lobe, Right or Lobe, Left) entered on the Living Donor Feedback displays.

Procedure Type: Indicate whether the procedure type was Open or Video Assisted Thoracoscopic. This field is required.

Conversion from Thoracoscopic to Open: If Open was selected for Procedure Type, and there was a conversion from thoracoscopic to an open procedure, select Yes. If there was no conversion, select No.

Intra-operative Complications: If there were any intra-operative complications, select Yes. If not, select No. This field is required.

If Yes, Specify: Select the complication(s) by clicking on the checkbox next to the complication. If Other Specify is selected, enter the name of the other complication in the Other Specify field.

Sacrifice of Second Lobe Specify
Anesthetic Complication Specify
Arrhythmia Requiring Therapy
Cerebrovasular Accident
Phrenic Nerve Injury
Brachial Plexus Injury
Breast Implant Rupture
Other Specify

Sacrifice of Second Lobe, Specify: If a second lobe was sacrificed, select the type from the drop-down list.

RML
RUL
LUL
Lingular

Anesthetic Complication Specify: If anesthetic complication occurred, enter the complication.

Arrhythmia requiring therapy: If there was arrhythmia requiring therapy, select the therapy from the drop-down list.

Medical therapy
Cardioversion

Post-Operative Information

This section displays for all organ types.

Date of Initial Discharge: Enter the date the donor was initially released to go home. Use the standard 8-digit format of MM/DD/YYYY. The donor's hospital stay includes total time spent in different units of the hospital, including medical and rehab. This field is required.

Donor Status: Select the status of the donor from the drop-down list. This field is required.

Living
Dead

Date Last Seen or Death: Enter the date the living donor was last seen. If the living donor died, enter the date of death. Use the standard 8-digit format of MM/DD/YYYY. This field is required.

Cause of Death: If the living donor died, indicate the cause of death. If the cause of death is not listed, select Other, specify and enter the cause of death in the Other specify field.

Infection: Donation/Surgery Related
Infection: Not Donation/Surgery Related
Pulmonary Embolism
Malignancy
Domino Liver Donor-Transplant Related Death (Liver donors only)
Cardiovascular
CVA
Hemorrhage: Donation/Surgery Related
Hemorrhage: Not Donation/Surgery Related
Homicide
Suicide
Accidental
Other, specify

Non-Autologous Blood Administration: If non-autologous blood was administered to the donor, select Yes. If not, select No. This field is required. Please include any blood products given from post-op through initial discharge.

If Yes, Number of Units: If non-autologous blood was administered to the donor, enter the number of units the donor received for the following types:

PRBC
Platelets
FFP

Liver Related Post-Operative Complications (When the living donor is discharged from the hospital or six-weeks following the transplant date, whichever is first)

This section displays if a liver was recovered from the donor or the procedure was aborted.

Biliary Complications: If the donor experienced biliary complications during the first 6 weeks after donation, select Yes. If not, select No. This field is required.

If Yes specify: Select the grade of complication by clicking on the circle next to the grade.

Grade 1 - Bilious JP drainage more than 10 days
Grade 2 - Interventional procedure (ERCP, PTC, percutaneous drainage, etc.)
Grade 3 - Surgical intervention

If Grade 3 is selected, enter the Date of Surgery using the standard 8-digit format of MM/DD/YYYY.

Vascular Complications Requiring Intervention: If the donor experienced vascular complications requiring intervention during the first 6 weeks after the donation, select Yes. If not, select No. This field is required.

If Yes, Specify: Select the complication(s) by clicking on the checkbox next to the complication. If Other, specify is selected, enter the name of the other complication in the Other Specify field.

Portal Vein
Hepatic Vein
Hepatic Artery
Pulmonary Embolus
Deep Vein Thrombosis
Other, Specify

Other Complications Requiring Intervention: If the donor experienced other complications requiring intervention during the first 6 weeks after the donation, select Yes. If not, select No. This field is required.

If Yes, Specify: Select the complication(s) by clicking on the checkbox next to the complication. If Other, specify is selected, enter the name of the other complication in the Other Specify field.

Renal insufficiency requiring dialysis
Ascites
Line or IV complication
Pneumothorax
Pneumonia
Wound Complication
Brachial Nerve Injury
Other, specify

Reoperation: If the donor required reoperation the first 6 weeks after the donation, select Yes. If not, select No. If unknown, select UNK. This field is required.

If Yes, specify reason for reoperation (during first six weeks): Specify the reason(s) by clicking on the checkbox next to the reason. Enter the Date for each reason selected using the standard 8-digit format of MM/DD/YYYY. If Other Specify is selected, enter the reason and the Date.

Liver Failure Requiring Transplant
Bleeding Complications
Hernia Repair
Bowel Obstruction
Vascular Complications
Other Specify

Any Readmission After Initial Discharge: If the donor required any readmission after the initial discharge during the first 6 weeks after the donation, select Yes. If not, select No. If unknown, select UNK. This field is required.

If yes, specify reason for readmission (during first six weeks): Select the reason from the drop-down list. If Other, specify is selected, enter the reason in the Specify field.

Wound infection
Fever
Bowel Obstruction
Pleural Effusion
Biliary Complications
Vascular Complications
Other, specify

If Yes, Date of First Readmission: Enter the date of the first readmission using the standard 8-digit format of MM/DD/YYYY.

Other Interventional Procedures: If the donor required other interventional procedures during the first 6 weeks after the donation, select Yes. If not, select No. If unknown, select UNK. This field is required.

If Yes, Specify Procedure: Enter the procedure.
Date of Procedure: Enter the date of the procedure using the standard 8-digit format of MM/DD/YYYY.

Kidney Related Post-Operative Complications (When the living donor is discharged from the hospital or six-weeks following the transplant date, whichever is first)

This section displays if a kidney was recovered from the donor or the procedure was aborted.

Vascular Complications Requiring Intervention: If the donor experienced vascular complications requiring intervention during the first 6 weeks after the donation, select Yes. If not, select No. This field is required.

If Yes, Specify: Select the complication(s) by clicking on the checkbox next to the complication. If Other, specify is selected, enter the name of the other complication in the Other Specify field.

Renal Vein
Renal Artery
Aorta
Vena Cava
Pulmonary Embolus
Deep Vein Thrombosis
Other, specify

Other Complications Requiring Intervention: If the donor experienced other complications requiring intervention during the first 6 weeks after the donation, select Yes. If not, select No. This field is required.

If Yes, Specify: Select the complication(s) by clicking on the checkbox next to the complication. If Other, specify is selected, enter the name of the other complication in the Other Specify field.

Renal insufficiency requiring dialysis
Ascites
Line or IV complication
Pneumothorax
Pneumonia
Wound Complication
Brachial Nerve Injury
Other, specify

Reoperation: If the donor required reoperation the first 6 weeks after the donation, select Yes. If not, select No. If unknown, select UNK. This field is required.

If Yes, specify reason for reoperation (during first six weeks): Specify the reason(s) by clicking on the checkbox next to the reason. Enter the Date for each reason selected. If Other Specify is selected, enter the reason and the Date.

Bleeding
Hernia Repair
Bowel Obstruction
Vascular
Other Specify

Any Readmission After Initial Discharge: If the donor required any readmission after the initial discharge during the first 6 weeks after the donation, select Yes. If not, select No. If unknown, select UNK. This field is required.

If yes, specify reason for readmission (during first six weeks): Select the reason from the drop-down list. If Other, specify is selected, enter the reason in the Specify field.

Wound infection
Fever
Bowel Obstruction
Pleural Effusion
Vascular Complications
Other, specify

If Yes, Date of First Readmission: Enter the date of the first readmission using the standard 8-digit format of MM/DD/YYYY.

Other Interventional Procedures: If the donor required other interventional procedures during the first 6 weeks after the donation, select Yes. If not, select No. If unknown, select UNK. This field is required.

If Yes, Specify Procedure: Enter the procedure.

Date of Procedure: Enter the date of the procedure using the standard 8-digit format of MM/DD/YYYY.

Lung Related Post-Operative Complications (When the living donor is discharged from the hospital or six-weeks following the transplant date, whichever is first)

This section displays if a lung was recovered from the donor or the procedure was aborted.

Post-operative complications during the initial hospitalization: If the donor experienced any post-operative complications during the initial hospitalization, select Yes. If not, select No. This field is required.

If Yes is selected, select the type of post-operative complications from the drop-down list.

Arrhythmia requiring therapy
Bleeding requiring surgical or therapeutic bronchoscopic intervention
Bowel obstruction or ileus not requiring surgical intervention
Bowel obstruction or ileus requiring surgical intervention
Bronchial Stenosis/Stricture not requiring surgical or therapeutic bronchoscopic intervention
Bronchial Stenosis/Stricture requiring surgical or therapeutic bronchoscopic intervention
Bronchopleural Fistula requiring surgical or therapeutic bronchoscopic intervention
Cerebrovascular Accident
Deep Vein Thrombosis
Empyema requiring therapeutic surgical intervention
Epidural-Related Complication
Line or IV Complication
Loculated pleural effusion requiring surgical intervention
Pericardial tamponade or pericarditis requiring surgical intervention
Pericarditis not requiring surgical intervention
Peripheral Nerve Injury
Phrenic Nerve Injury
Placement of Additional Thoracostomy Tube(s), Specify Indication
Pneumonia/Atelectasis
Prolonged (>14 days) Thoracostomy Tube Requirement
Pulmonary Artery Embolus or Thrombosis
Pulmonary Vein or Left Atrial Thrombosis
Wound Complication
Wound infection requiring surgical intervention
Other Specify

Arrhythmia requiring therapy: Indicate if the donor received Medical therapy, Cardioversion or Electrophysiologic Ablation.

Placement of Additional Thoracostomy Tube(s), Indication: Select the placement of the tubes from the drop-down list.

Pneumothorax
Pleural effusion
Empyema

Other Specify: Enter the therapy.

Any readmission After Initial Discharge: If the donor required any readmission after the initial discharge during the first 6 weeks after the donation, select Yes. If not, select No. If unknown, select UNK. This field is required.

If yes, specify reason for readmission (during first six weeks): Select the reason from the drop-down list. If Other, specify is selected, enter the reason in the Specify field.

Wound infection
Fever
Bowel Obstruction
Pleural Effusion
Vascular Complications
Other, specify

If Yes, Date of First Readmission: Enter the date of the first readmission using the standard 8-digit format of MM/DD/YYYY.

Post-Operative Clinical Information (When the living donor is discharged from the hospital or six-weeks following the transplant date, whichever is first)

The following questions display for all donated organs:

Most Recent Date of Tests: Enter the date of the donor's most recent tests in the space provided using the standard 8-digit numeric format of MM/DD/YYYY. The tests should reflect an individual’s clinical characteristics at the time of discharge or six-weeks after the transplant date, whichever is first.

Weight: Enter the weight of the donor in lb (pounds) or kg (kilograms). This field is required. If the donor's weight is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

The following questions display for donated kidney organs only.

Donor Kidney Post-Op Creatinine//Serum Creatinine: Enter the lab value for the kidney donor's serum creatinine value in mg/d. The tests should reflect the serum creatinine at the time of discharge or six-weeks after the transplant date, whichever is first.

. This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Post-Op Blood Pressure Systolic: Enter the donor's systolic blood pressure in the space provided. The value should reflect an individual’s systolic blood pressure at the time of discharge or six-weeks after the transplant date, whichever is first.

This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Post-Op Blood Pressure Diastolic: Enter the donor's diastolic blood pressure in the space provided. The value should reflect an individual’s diastolic blood pressure at the time of discharge or six-weeks after the transplant date, whichever is first. This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Urinalysis: Enter the donor's Protein-Creatinine Ratio or Urine Protein. This is a required field.

If Urine Protein is selected, select the result from the drop-down list.

Positive
Negative
Unknown
Not Done

Donor Developed Hypertension Requiring Medication: If the donor developed hypertension at discharge or within 6 weeks after donation (whichever is first) that required medication, select Yes. If not, select No. If unknown, select UNK. This field is required.

The following questions display for donated liver organs only:

Total Bilirubin: Enter the lab value for total serum bilirubin in mg/dl. This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

SGOT/AST: Enter the lab value for the serum glutamic oxaloacetic transaminase or aspartate transaminase in U/L. (This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

SGPT/ALT: Enter the lab value for Serum Glutamic Pyruvic Transaminase/Alanine Aminotransferase in U/L. (This is a required field.) If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Alkaline Phosphatase: Enter the lab value for the serum alkaline phosphatase value in units/L. This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Serum Albumin: Enter the lab value for the serum albumin value in g/dl. This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Serum Creatinine: Enter the lab value for the serum creatinine value in mg/dl. This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

INR: International Normalized Ratio. Enter the ratio of the prothrombin time (in seconds) to the control prothrombin time (in seconds). This field is required. If the value is not available, select the reason from the status (ST) drop-down list (Missing, Unknown, N/A, Not Done).

Organ Recovery

Organ Recovery Date: The date of the donor's recovered organ reported in the Living Donor Feedback will display. Verify that the displayed date is the date the organ(s) was recovered from this donor. If the date is blank or incorrect, use the standard 8-digit numeric format of MM/DD/YYYY to enter the correct date. If the operation was started in the evening and concluded the next day, enter the date the operation began. This field is required.

Organ(s) Recovered: The donor's organ(s) reported as being recovered in the Living Donor Feedback will display. Verify the organ(s) displayed in the record are the organs recovered from this donor. Verify that the correct organ modifier (right or left) is displayed in the record.

Right Kidney
Left Kidney
Pancreas Segment
Liver Segment
Intestine Segment
Living Donor Heart Transplant
Right Single Lung
Left Single Lung
Left Lung Lobe
Right Lung Lobe
Domino Whole Liver

Recipient Name (Last, First): The recipient's name reported in the Recipient and Living Donor Feedback will display. Verify that the displayed name is the name of the recipient who received this organ.

Recipient SSN#: The recipient's social security number reported in the Recipient and Living Donor Feedback will display. Verify the social security number of the recipient.

Donor Recovery Facility: This will default with the same center as Donor Workup Facility, but can be changed if the organ was recovered at a different center. The drop-down list contains the names of all national Transplant Centers. This field is required.

Donor Workup Facility: This is the name of the center that entered the Living Donor information into UNet^SM. This cannot be modified.