36 Kidney Transplant Recipient Registration_Form.xlsx

TRR - Kidney - Adult
Fields to be completed by members					Fields to be completed by members
Form Section	Field Label	Notes		Form Section	Field Label	Notes
1- Recipient Information	Organ	Display Only - Cascades from TCR		1- Recipient Information	Organ	Display Only - Cascades from TCR
1- Recipient Information	Recipient First Name	Display Only - Cascades from TCR		1- Recipient Information	Recipient First Name	Display Only - Cascades from TCR
1- Recipient Information	Recipient Last Name	Display Only - Cascades from TCR		1- Recipient Information	Recipient Last Name	Display Only - Cascades from TCR
1- Recipient Information	Recipient Middle Initial	Not required		1- Recipient Information	Recipient Middle Initial	Not required
1- Recipient Information	SSN	Display Only - Cascades from TCR		1- Recipient Information	SSN	Display Only - Cascades from TCR
1- Recipient Information	HIC	Display Only - Cascades from TCR		1- Recipient Information	HIC	Display Only - Cascades from TCR
1- Recipient Information	DOB	Display Only - Cascades from TCR		1- Recipient Information	DOB	Display Only - Cascades from TCR
1- Recipient Information	Gender	Display Only - Cascades from TCR		1- Recipient Information	Gender	Display Only - Cascades from TCR
1- Recipient Information	Tx Date	Display Only - Cascades from feedback		1- Recipient Information	Tx Date	Display Only - Cascades from feedback
1- Recipient Information	State of Permanent Residence			1- Recipient Information	State of Permanent Residence
1- Recipient Information	Permanent Zip			1- Recipient Information	Permanent Zip
2 - Provider Information	Recipient Center Code	Display Only - Cascades from TCR		2 - Provider Information	Recipient Center Code	Display Only - Cascades from TCR
2 - Provider Information	Recipient Center Type	Display Only - Cascades from TCR		2 - Provider Information	Recipient Center Type	Display Only - Cascades from TCR
2 - Provider Information	Surgeon Name			2 - Provider Information	Surgeon Name
2 - Provider Information	NPI#			2 - Provider Information	NPI#
3 - Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback		3 - Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback
3 - Donor Information	Donor Type	Display Only - Cascades from feedback		3 - Donor Information	Donor Type	Display Only - Cascades from feedback
3 - Donor Information	OPO	Display Only - Cascades from feedback		3 - Donor Information	OPO	Display Only - Cascades from feedback
4 - Patient Status	Primary Diagnosis			4 - Patient Status	Primary Diagnosis
4 - Patient Status	Primary Diagnosis//Specify			4 - Patient Status	Primary Diagnosis//Specify
4 - Patient Status	Date: Last Seen, Retransplanted or Death			4 - Patient Status	Date: Last Seen, Retransplanted or Death
4 - Patient Status	Patient Status			4 - Patient Status	Patient Status
4 - Patient Status	Primary Cause of Death			4 - Patient Status	Primary Cause of Death
4 - Patient Status	Cause of Death//Specify			4 - Patient Status	Cause of Death//Specify
4 - Patient Status	Contributory Cause of Death	Not required		4 - Patient Status	Contributory Cause of Death	Not required
4 - Patient Status	Contributory Cause of Death//Specify	Not required		4 - Patient Status	Contributory Cause of Death//Specify	Not required
4 - Patient Status	Contributory Cause of Death	Not required		4 - Patient Status	Contributory Cause of Death	Not required
4 - Patient Status	Contributory Cause of Death//Specify	Not required		4 - Patient Status	Contributory Cause of Death//Specify	Not required
4 - Patient Status	Date of Admission to Tx Center			4 - Patient Status	Date of Admission to Tx Center
4 - Patient Status	Date of Discharge from Tx Center			4 - Patient Status	Date of Discharge from Tx Center
4 - Patient Status	Functional Status			4 - Patient Status	Functional Status
4 - Patient Status	Working for income			4 - Patient Status	Academic Progress
4 - Patient Status	Primary Source of Payment			4 - Patient Status	Academic Activity Level
4 - Patient Status	Specify Foreign Government//Specify			4 - Patient Status	Primary Source of Payment
5- PreTransplant	Height			4 - Patient Status	Specify Foreign Government//Specify
5- PreTransplant	Height in Centimeters//Status	Value or status is reported, not both		4 - Patient Status	Cognitive Development
5- PreTransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only		4 - Patient Status	Motor Development
5- PreTransplant	Weight			5- Pretransplant	Date of Measurement
5- PreTransplant	Weight in Kilograms//Status	Value or status is reported, not both		5- PreTransplant	Height
5- PreTransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only		5- PreTransplant	Height in Centimeters//Status	Value or status is reported, not both
5- PreTransplant	BMI	Display Only - Cascades from Database		5- PreTransplant	Height Percentile//Growth Percentiles//%ile	Calculated for display only
5- PreTransplant	BMI://%ile	Calculated for display only		5- PreTransplant	Weight
6- PreTransplant	Previous Transplant Organ	Display Only - Cascades from Database		5- PreTransplant	Weight in Kilograms//Status	Value or status is reported, not both
6- PreTransplant	Previous Transplant Date	Display Only - Cascades from Database		5- PreTransplant	Weight Percentile//Growth Percentiles//%ile	Calculated for display only
6- PreTransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database		5- PreTransplant	BMI	Display Only - Cascades from Database
6- PreTransplant	Pretransplant Dialysis			5- PreTransplant	BMI://%ile	Calculated for display only
6- PreTransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis			6- PreTransplant	Previous Transplant Organ	Display Only - Cascades from Database
6- PreTransplant	Date First Dialyzed//Status	Value or status is reported, not both		6- PreTransplant	Previous Transplant Date	Display Only - Cascades from Database
6- PreTransplant	Serum Creatinine at Time of Tx			6- PreTransplant	Previous Transplant Graft Fail Date	Display Only - Cascades from Database
6- PreTransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both		6- PreTransplant	Pretransplant Dialysis
6- PreTransplant	HIV Serostatus			6- PreTransplant	If Dialyzed, Date of Most Recent Initiation of Chronic Maintenance Dialysis
5- PreTransplant	NAT HIV			6- PreTransplant	Date First Dialyzed//Status	Value or status is reported, not both
5- PreTransplant	CMV Status			6- PreTransplant	Serum Creatinine at Time of Tx
6- PreTransplant	HBV Core Antibody			6- PreTransplant	Serum Creatinine at Time of Tx//Status	Value or status is reported, not both
5- PreTransplant	HBV Surface Antibody Total			6- PreTransplant	HIV Serostatus
6- PreTransplant	HBV Surface Antigen			5- PreTransplant	NAT HIV
5- PreTransplant	NAT HBV			6- PreTransplant	CMV Status
6- PreTransplant	HCV Serostatus			6- PreTransplant	HBV Core Antibody
5- PreTransplant	NAT HCV			6- PreTransplant	HBV Surface Antibody Total
6- PreTransplant	EBV Serostatus			6- PreTransplant	HBV Core Antibody
6- PreTransplant	Previous Pregnancies			6- PreTransplant	HBV Surface Antigen
6- PreTransplant	Malignancies between listing and transplant			5- PreTransplant	NAT HBV
6- PreTransplant	If yes, specify type			6- PreTransplant	HCV Serostatus
6- PreTransplant	Malignancies between listing and transplant//Specify			5- PreTransplant	NAT HCV
7 - Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback		6- PreTransplant	EBV Serostatus
7 - Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback		6- PreTransplant	Malignancies between listing and transplant
7 - Transplant Procedure	Procedure Type	Display Only - Cascades from feedback		6- PreTransplant	If yes, specify type
7 - Transplant Procedure	Total Cold ischemia Time Right KI(OR EN-BLOC): (if pumped, include pump time)			6- PreTransplant	Malignancies between listing and transplant//Specify
7-Transplant Procedure	Total Cold Ischemia Time//Status	Value or status is reported, not both		6- PreTransplant	Fracture in the past year (or since last follow-up)
7-Transplant Procedure	Total Cold ischemia Time Left KI (if pumped, include pump time)			6- PreTransplant	Spine-compression fracture
7-Transplant Procedure	Total Cold Ischemia Time//Status	Value or status is reported, not both		6- PreTransplant	Spine-compression fracture//# of fractures
7-Transplant Procedure	Kidney(s) received on			6- PreTransplant	Extremity
7-Transplant Procedure	Received on ice			6- PreTransplant	Extremity//# of fractures
7-Transplant Procedure	Received on pump			6- PreTransplant	Other
7-Transplant Procedure	Left Kidney Final resistance at transplant			6- PreTransplant	Other//# of fractures
7-Transplant Procedure	Left Kidney Final resistance at tx//Status	Value or status is reported, not both		6- PreTransplant	AVN (avascular necrosis)
7-Transplant Procedure	Right Kidney Final resistance at transplant			7 - Transplant Procedure	Multiple Organ Recipient	Display Only - Cascades from feedback
7-Transplant Procedure	Right Kidney Final resistance at tx//Status	Value or status is reported, not both		7 - Transplant Procedure	Were extra vessels used in the transplant procedure	Display Only - Cascades from feedback
7-Transplant Procedure	Left Kidney Final flow rate at transplant			7 - Transplant Procedure	Procedure Type	Display Only - Cascades from feedback
7-Transplant Procedure	Left Kidney Final flow rate at tx//Status	Value or status is reported, not both		7 - Transplant Procedure	Total Cold ischemia Time Right KI(OR EN-BLOC): (if pumped, include pump time)
7-Transplant Procedure	Right Kidney Final flow rate at transplant			7-Transplant Procedure	Total Cold Ischemia Time//Status	Value or status is reported, not both
7-Transplant Procedure	Right Kidney Final flow rate at tx//Status	Value or status is reported, not both		7-Transplant Procedure	Total Cold ischemia Time Left KI (if pumped, include pump time)
8- Post Transplant	Graft Status			7-Transplant Procedure	Total Cold Ischemia Time//Status	Value or status is reported, not both
8- Post Transplant	Date of Graft Failure:			7-Transplant Procedure	Kidney(s) received on
8- Post Transplant	Primary Cause of Graft Failure:			7-Transplant Procedure	Received on ice
8- Post Transplant	Primary Cause of Graft Failure//Other, Specify:			7-Transplant Procedure	Received on pump
8 - PostTransplant	Resumed Maintenance Dialysis			7-Transplant Procedure	Left Kidney Final resistance at transplant
8 - PostTransplant	Date Maintenance Dialysis Resumed			7-Transplant Procedure	Left Kidney Final resistance at tx//Status	Value or status is reported, not both
8 -Post Reansplant	Most Recent Serum Creatinine Prior to Discharge			7-Transplant Procedure	Right Kidney Final resistance at transplant
8 -Post Reansplant	Most Recent Serum Creatinine Prior to Disch.//Status	Value or status is reported, not both		7-Transplant Procedure	Right Kidney Final resistance at tx//Status	Value or status is reported, not both
8 - PostTransplant	Patient Need Dialysis within First Week			7-Transplant Procedure	Left Kidney Final flow rate at transplant
8 - PostTransplant	Did patient have any acute rejection episodes between transplant and discharge			7-Transplant Procedure	Left Kidney Final flow rate at tx//Status	Value or status is reported, not both
9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection			7-Transplant Procedure	Right Kidney Final flow rate at transplant
9- Immunosupression Other	immunosuppression medication			7-Transplant Procedure	Right Kidney Final flow rate at tx//Status	Value or status is reported, not both
9- Immunosupression Other	immunosuppression medication indication			8- Post Transplant	Graft Status
9- Immunosupression Other	days of induction			8- Post Transplant	Date of Graft Failure:
				8- Post Transplant	Primary Cause of Graft Failure:
	Public Burden Statement			8- Post Transplant	Primary Cause of Graft Failure//Other, Specify:
				8 - PostTransplant	Resumed Maintenance Dialysis
				8 - PostTransplant	Date Maintenance Dialysis Resumed
				8 -Post Reansplant	Most Recent Serum Creatinine Prior to Discharge
				8 -Post Reansplant	Most Recent Serum Creatinine Prior to Disch.//Status	Value or status is reported, not both
				8 - PostTransplant	Patient Need Dialysis within First Week
				8 - PostTransplant	Did patient have any acute rejection episodes between transplant and discharge
				6- PreTransplant	Is growth hormone therapy used between listing and transplant
				9- Immunosupression Other	Are any medications given currently for maintenance or anti-rejection
				9- Immunosupression Other	immunosuppression medication
				9- Immunosupression Other	immunosuppression medication indication
				9- Immunosupression Other	days of induction
					Public Burden Statement