Form 2 SRTR Candidate Reasons Did Not Donate_Liver and Kidney F

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

2. 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:

28. Psychiatric illness

29. Multiple psychosocial stressors

30. Limited psychosocial support

31. Donor conflicted or felt coerced

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

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

34. Limitation on taking time off work

35. Economic burden of donation

36. Lack of health insurance coverage

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

Other:

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

39. Intended recipient underwent deceased donor transplant

40. Intended recipient decided not to undergo transplant

41. Intended recipient decided not to have this candidate donate

42. Intended recipient became too ill for transplant

43. Intended recipient died

44. Intended recipient liver function improved

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

46. Decided against donation for undisclosed reason(s)

47. Candidate declined after deciding risk was too high

48. Missed appointments or became unavailable

49. 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:

32. Psychiatric illness

33. Multiple psychosocial stressors

34. Limited psychosocial support

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

36. Donor conflicted or felt coerced

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

38. Lack of health insurance coverage

39. Economic burden of donation

40. Limitation on taking time off work

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

Other:

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

43. Intended recipient underwent deceased donor transplant

44. Intended recipient decided not to undergo transplant

45. Intended recipient decided not to have this candidate donate

46. Intended recipient became too ill for transplant

47. Intended recipient died

48. Intended recipient kidney function improved

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

50. Decided against donation for undisclosed reason(s)

51. Candidate declined after deciding risk was too high

52. Missed appointments or became unavailable

53. 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.