20b Kidney-Pancreas Adult Transplant Recipient Follow Up Wor

Records
Adult Kidney-Pancreas Transplant Recipient 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 Discharge Date:
State of Permanent Residence:

Zip Code:

-

Provider Information
Recipient Center:
Followup Center:

Physician Name:
NPI#:

Transplant Center

Non Transplant Center Specialty Physician
Follow-up Care Provided By:
Primary Care Physician

Other Specify

Specify:

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):

Kidney

Pancreas

Kidney/Pancreas

Primary Cause of Death:
Specify:

Contributory Cause of Death:
Specify:

Contributory Cause of Death:
Specify:

Hospitalizations:

YES
Has the patient been hospitalized since the last patient status date:
NO

UNK

Number of Hospitalizations:

ST=

Noncompliance:

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

NO

UNK

Functional Status:

No Limitations

Limited Mobility
Physical Capacity:

Wheelchair bound or more limited

Not Applicable (< 1 year old or hospitalized)

Unknown

Working for income:

YES

NO

UNK

If No, Not Working Due To:

Working Full Time

Working Part Time due to Demands of Treatment

Working Part Time due to Disability

Working Part Time due to Insurance Conflict
If Yes:
Working Part Time due to Inability to Find Full Time Work

Working Part Time due to Patient Choice

Working Part Time Reason Unknown

Working, Part Time vs. Full Time Unknown

Within One Grade Level of Peers

Delayed Grade Level
Academic Progress:

Special Education

Not Applicable < 5 years old/ High School graduate or GED

Status Unknown

Full academic load
Academic Activity Level:
Reduced academic load

Unable to participate in academics due to disease or condition

Not Applicable < 5 years old/ High School graduate or GED

Status Unknown

Primary Insurance at Follow-up:
Specify:

Clinical Information

Height:

ft.

Weight:
BMI:

Urine Protein Found By Any Method:

Kidney Graft Status:

in.

lbs.
kg/m

cm

ST=

kg

ST=

2

YES

NO

Functioning

UNK

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
Contributory causes of graft failure:

Kidney Acute Rejection

YES

NO

UNK

Kidney Chronic Rejection

YES

NO

UNK

Kidney Graft Thrombosis

YES
UNK

NO

YES

Kidney Infection

NO

UNK

YES

Urological Complications

NO

UNK

YES

Patient Noncompliance

NO

UNK

YES

Recurrent Disease:

NO

UNK

YES

BK (Polyoma) Virus

UNK
Kidney Other Contributory Cause of Graft Failure

If Functioning, Most Recent Serum Creatinine:

mg/dl

ST=

NO

YES, RESUMED MAINTENANCE DIALYSIS
Dialysis Since Last Follow-Up:

YES, NO MAINTENANCE RESUMPTION

YES, MAINTENANCE RESUMPTION UNKNOWN

UNKNOWN

Date Maintenance Dialysis Resumed:

Select a Dialysis Provider:
Provider #:
Provider Name:

Pancreas Graft Status:

Functioning

Partial Function

Failed

If death is indicated for the recipient, and the death was a result of some other factor unrelated to graft failure, select Functioning.

NO

Insulin

Oral medication
Method of blood sugar control:
Diet

No Treatment
Date insulin/medication resumed:

Pancreas Date of Failure

Pancreas Graft Removed:

YES

NO

UNK
Date Pancreas Removed:
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

NO

UNK

Biopsy Proven Isletitis

YES

NO

UNK

YES

Pancreatitis

NO

UNK

YES

Patient Noncompliance

UNK
Other, Specify:

Conv. From Bladder to Enteric Drain Performed:

YES

NO

UNK

Enteric Drain Date:

Serum Amylase:

u/L

ST=

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

Anastomotic Leak

Abcess or Local Infection

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

Other, Specify:

Yes, at least one episode treated with anti-rejection agent

Did patient have any kidney acute rejection episodes
during the follow-up period:

Yes, none treated with additional anti-rejection agent

No

Unknown

Biopsy not done
Was biopsy done to confirm acute rejection:

Yes, rejection confirmed

Yes, rejection not confirmed

NO

Unknown

Yes, at least one episode treated with anti-rejection agent

Did patient have any pancreas acute rejection episodes
during the follow-up period:

Yes, none treated with additional anti-rejection agent

No

Unknown

Biopsy not done

Yes, rejection confirmed
Was biopsy done to confirm acute rejection:
Yes, rejection not confirmed

Unknown

Viral Detection:

Positive

Negative
CMV IgG:
Not Done

UNK/Cannot Disclose

Positive

Negative
CMV IgM:
Not Done

UNK/Cannot Disclose

Post Transplant Malignancy:

Donor Related:

Recurrence of Pre-Tx Tumor:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

De Novo Solid Tumor:

De Novo Lymphoproliferative disease and Lymphoma:

YES

NO

UNK

YES

NO

UNK

Treatment

Biological or Anti-viral therapy:

YES

NO

Unknown/Cannot disclose

Acyclovir (Zovirax)

Cytogam (CMV)

Gamimune

Gammagard

Ganciclovir (Cytovene)
If Yes, check all that apply:

Valgancyclovir (Valcyte)

HBIG (Hepatitis B Immune Globulin)

Flu Vaccine (Influenza Virus)

Lamivudine (Epivir) (for treatment of Hepatitis B)

Valacyclovir (Valtrex)

Other, Specify

Specify:
Specify:

Treatment for BK (polyoma) virus:

YES

NO

Yes, Immunosuppression reduction

Yes, Cidofovir
If Yes, check all that apply:
Yes, IVIG

Yes, Type Unknown

Yes, Other, Specify

Specify:

Other therapies:

YES

NO

Photopheresis
If Yes, check all that apply:

Plasmapheresis

Total Lymphoid Irradiation (TLI)

Immunosuppressive Information
Previous Validated Maintenance Follow-Up Medications:
Previous Validated Maintenance Follow-Up Medications:

Yes, same as validated TRR form

Were any medications given during the follow-up period for
maintenance:

Yes, same as previous validated report

Yes, but different than previous validated report

None given

Did the physician discontinue all maintenance
immunosuppressive medications:

YES

NO

Did the patient participate in any clinical research protocol
for immunosuppressive medications:

YES

NO

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 Antirejection (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 nonimmunosuppressive medications.

For each of the immunosuppressive medications listed, select Ind (Induction), Maint (Maintenance) or AR (Anti-rejection) to indicate all medications
that were prescribed for the recipient during the initial transplant hospitalization period, and for what reason. If a medication was not given, leave the
associated box(es) blank.
Induction (Ind) immunosuppression includes all medications given for a short finite period in the perioperative period for the purpose of preventing
acute rejection. Though the drugs may be continued after discharge for the first 30 days after transplant, it will not be used long-term for
immunosuppressive maintenance. Induction agents are usually polyclonal, monoclonal, or IL-2 receptor antibodies (example: Methylprednisolone,
Atgam, Thymoglobulin, OKT3, Simulect, or Zenapax). Some of these drugs might be used for another finite period for rejection therapy and would be
recorded as rejection therapy if used for this reason. For each induction medication indicated, write the total number of days the drug was actually
administered in the space provided. For example, if Simulect or Zenapax was given in 2 doses a week apart, then the total number of days would be 2,
even if the second dose was given after the patient was discharged.
Maintenance (Maint) includes all immunosuppressive medications given before, during or after transplant 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, or for induction.
Anti-rejection (AR) immunosuppression includes all immunosuppressive medications given for the purpose of treating an acute rejection episode
during the initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection (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.
If an immunosuppressive medication other than those listed is being administered (e.g., new monoclonal antibodies), select Ind, 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
Steroids
(Prednisone,Methylprednisolone,Solumedrol,Medrol,Decadron)
Atgam (ATG)
OKT3 (Orthoclone, Muromonab)
Thymoglobulin
Simulect - Basiliximab
Zenapax - Daclizumab
Azathioprine (AZA, Imuran)
EON (Generic Cyclosporine)
Gengraf (Abbott Cyclosporine)
Other generic Cyclosporine, specify brand:
Neoral (CyA-NOF)

Curr Maint

AR

Sandimmune (Cyclosporine A)
CellCept (Mycophenolate Mofetil; MMF)
Generic MMF (Generic CellCept)
Prograf (Tacrolimus, FK506)
Generic Tacrolimus (Generic Prograf)
Advagraf (Tacrolimus Extended or Modified Release)
Nulojix (Belatacept)
Sirolimus (RAPA, Rapamycin, Rapamune)
Myfortic (Mycophenolate Sodium)

Other Immunosuppressive Medications
Prev Maint

Curr Maint

AR

Prev Maint

Curr Maint

AR

Campath - Alemtuzumab (anti-CD52)
Cyclophosphamide (Cytoxan)
Leflunomide (LFL, Arava)
Methotrexate (Folex, PFS, Mexate-AQ, Rheumatrex)
Other Immunosuppressive Medication, Specify
Rituximab

Investigational Immunosuppressive Medications

Zortress (Everolimus)
Other Immunosuppressive Medication, Specify