Form 2 SRTR Candidate Reasons Did Not Donate_Liver and Kidney F

Scientific Registry of Transplant Recipients Information Collection Effort for Potential Donors for Living Organ Donation (SRTR)

SRTR Candidate Reasons Did Not Donate_Liver and Kidney Form_10-11-17

Scientific Registry of Transplant Recipients Information Collection Effort for Potential Donors for Living Organ Donation

OMB: 0906-0034

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OMB Number: 0916-XXXX

Expiration Date: XX/XX/20XX

Liver Candidate Reasons Did Not Donate

  1. At the time a decision was made, the evaluation of the donor candidate (check best answer):

  • Was complete

  • Lacked a few components of the evaluation

  • Lacked many components of the evaluation


  1. Indicate reason(s) the candidate did not donate (circle any and all that apply). Except where indicated, all reasons on this list apply to the donor candidate and not to the intended recipient.


Please circle any and all that apply in any of the following three categories:

Categories: (circle any and all that apply):
Medical:

    1. Age – too old

    2. Age – too young

    3. Concern for future pregnancy and childbirth

    4. Recent/current malignancy

    5. Newly detected mass or malignancy

    6. Liver disease

    7. Hypercoagulable state

    8. Vascular or biliary anatomic abnormalities on imaging

    9. Inadequate liver volumes on imaging

    10. Other unfavorable anatomical abnormality on imaging

    11. Donor liver steatosis on imaging or biopsy

    12. Other biopsy abnormalities

    13. Cardiovascular disease

    14. Diabetes

    15. Concern for risk of diabetes

    16. Obesity

    17. Hypertension

    18. High cholesterol and/or high triglycerides

    19. Incompatible blood group for the intended recipient

    20. Family history of cardiovascular disease

    21. Incompatible blood group with the intended recipient

    22. Recipient HLA antibodies to the donor candidate

    23. Risk of transmitting an infection to the intended recipient

    24. Tobacco use

    25. Substance use disorder

    26. Another living donor candidate was a better HLA match

    27. Another living donor candidate was a better choice for medical reasons



Psychosocial:

    1. Psychiatric illness

    2. Multiple psychosocial stressors

    3. Limited psychosocial support

    4. Donor conflicted or felt coerced

    5. Unable to provide informed consent due to cognitive impairment or a developmental disability

    6. Member(s) of family against the candidate donating

    7. Limitation on taking time off work

    8. Economic burden of donation

    9. Lack of health insurance coverage

    10. Another living donor candidate was a better choice for psychosocial reasons

Other:

    1. Another living donor candidate was a better choice for other reasons

    2. Intended recipient underwent deceased donor transplant

    3. Intended recipient decided not to undergo transplant

    4. Intended recipient decided not to have this candidate donate

    5. Intended recipient became too ill for transplant

    6. Intended recipient died

    7. Intended recipient liver function improved

    8. Intended recipient did not use the candidate for other reasons

    9. Decided against donation for undisclosed reason(s)

    10. Candidate declined after deciding risk was too high

    11. Missed appointments or became unavailable

    12. Other, specify: _______________________________________



Kidney Candidate Reasons Did Not Donate

At the time a decision was made, the evaluation of the donor candidate (check best answer):

  • Was complete

  • Was complete except for imaging study

  • Lacked imaging study and a few components of the evaluation

  • Lacked imaging study and many components of the evaluation


Indicate reason(s) the candidate did not donate (circle any and all that apply). Except where indicated all reasons on this list apply to the donor candidate and not to the intended recipient. Please circle any and all that apply in any of the following three categories:


Categories: (circle any and all that apply):

Medical:

  1. Age – too old

  2. Age – too young

  3. Concern for future pregnancy and childbirth

  4. Unwilling to discontinue medications potentially toxic to the kidney

  5. Recent/current malignancy

  6. Newly detected mass or malignancy

  7. Liver disease

  8. Cardiovascular disease

  9. Diabetes

  10. Concern for risk of diabetes.

  11. Risk of hereditary kidney disease

  12. Obesity

  13. Hypertension

  14. High cholesterol and/or high triglycerides

  15. Hematuria

  16. Proteinuria

  17. Low kidney function

  18. Kidney stones

  19. Kidney cysts

  20. Renal artery fibromuscular dysplasia

  21. Multiple renal arteries or veins

  22. Other disease involving the renal arteries (atherosclerotic disease, aneurysm)

  23. Kidney(s) too small

  24. Other unfavorable anatomical abnormality

  25. Incompatible blood group with the intended recipient

  26. Recipient HLA antibodies to the donor candidate

  27. Risk of transmitting an infection to the intended recipient

  28. Tobacco use

  29. Substance use disorder

  30. Another living donor candidate was a better HLA match

  31. Another living donor candidate a better choice for medical reasons

Psychosocial:

  1. Psychiatric illness

  2. Multiple psychosocial stressors

  3. Limited psychosocial support

  4. Unable to provide informed consent due to cognitive impairment or a developmental disability

  5. Donor conflicted or felt coerced

  6. Member(s) of family against the candidate donating

  7. Lack of health insurance coverage

  8. Economic burden of donation

  9. Limitation on taking time off work

  10. Another living donor candidate was a better choice for psychosocial reasons

Other:

  1. Another living donor candidate was a better choice for other reasons

  2. Intended recipient underwent deceased donor transplant

  3. Intended recipient decided not to undergo transplant

  4. Intended recipient decided not to have this candidate donate

  5. Intended recipient became too ill for transplant

  6. Intended recipient died

  7. Intended recipient kidney function improved

  8. Intended recipient did not use the candidate for other reasons

  9. Decided against donation for undisclosed reason(s)

  10. Candidate declined after deciding risk was too high

  11. Missed appointments or became unavailable

  12. Other, specify: _______________________________________






Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0916–XXXX. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, MD 20857.


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