20 Kidney-Pancreas Adult Post 5 Year Transplant Recipient F

Records
Adult Kidney-Pancreas 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 Follow-Up:

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

If Retransplanted, choose organ(s):

Primary Cause of Death:
Specify:

Kidney

Pancreas

Kidney/Pancreas

Clinical Information

Kidney Graft Status:

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.
Kidney Date of Failure:
Kidney Primary Cause of Graft Failure:

Specify

If Functioning, Most Recent Serum Creatinine:

Pancreas Graft Status:

mg/dl

Functioning

ST=

Partial Function

Failed

Pancreas Date of Failure
Pancreas Primary Causes of Graft Failure

Specify:
Contributory causes of graft failure:

Pancreas Graft/Vascular Thrombosis

YES

NO

UNK

Pancreas Infection

YES

NO

UNK

Pancreas Bleeding

YES

NO

UNK

Anastomotic Leak

YES

NO

UNK

Pancreas Rejection: Acute

YES

NO

UNK

Pancreas Chronic Rejection

YES
UNK

NO

YES

Biopsy Proven Isletitis

NO

UNK

YES

Pancreatitis

NO

UNK

YES

Patient Noncompliance

UNK
Other, Specify:

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

NO