HEPC Registry: Follow-up Record

See also: Clinical Trials Registry		See also: Scientific Models and Resources Registry
HEPC Registry: Follow-up Record

You will need the patient's Social Security Number. No update can be made otherwise.

Patient's SSN: (ex: 123-45-6789)
Date of primary transplant:

Is the patient alive: Yes No
If No, then date of death:
Cause of death:
Infection Cardiovascular Failure Graft Failure
Respiratory Failure Malignancy Recurrent Liver Disease
Sepsis Trauma/Accident Unknown
Other - Explain:

If patient is alive, is graft described in original data still functioning? Yes No
If no, cause of graft loss:
PNF HAT Infection Recurrent Hepatitis C Acute Rejection
Chronic Other Death Unknown
If other, then explain:

Date of retransplant:

In the last 12 Months:
Did the patient undergo biopsy? Yes No

Field Names	1st Biopsy	2nd Biopsy	3rd Biopsy	4th Biopsy
Date
The biopsy allowed	Normal Acute Rejection Chronic Rejection Hepatitis	Normal Acute Rejection Chronic Rejection Hepatitis	Normal Acute Rejection Chronic Rejection Hepatitis	Normal Acute Rejection Chronic Rejection Hepatitis
If biopsy showed acute rejection	Mild Moderate Severe	Mild Moderate Severe	Mild Moderate Severe	Mild Moderate Severe
If biopsy showed hepatitis	Hep C Alone Hep C w/rejection Chronic active hep Fibrosing Cholestatic Hep Cirrhosis	Hep C Alone Hep C w/rejection Chronic active hep Fibrosing Cholestatic Hep Cirrhosis	Hep C Alone Hep C w/rejection Chronic active hep Fibrosing Cholestatic Hep Cirrhosis	Hep C Alone Hep C w/rejection Chronic active hep Fibrosing Cholestatic Hep Cirrhosis
If hepatitis, portal inflamation	None Mild Moderate Severe	None Mild Moderate Severe	None Mild Moderate Severe	None Mild Moderate Severe
Piecemeal Necrosis	No Yes	No Yes	No Yes	No Yes
If Hepatitis, Fibrosis	None/Peri Portal Bridging Cirrhosis	None/Peri Portal Bridging Cirrhosis	None/Peri Portal Bridging Cirrhosis	None/Peri Portal Bridging Cirrhosis

Did ANY biopsy reveal Hepatitis C with rejection? No Yes

If Yes Date of Biopsy:

Treated with Steriods: No Yes

Normalization of LFTs: No Yes

Most recent Labs (date):

SGOT:

SGPT:

GGTP:

T. Bili:

Creatinine:

HCV RNA: x10^5 Date of RNA:

Present Immunosupression Dose:

Tacrolimus:

Cylcosporine:

Prednisone:

Azathroprine:

Mycophenolate mofetil:

Additional Steriod boluses over past year (total number of grams):

Treated with interferon: No Yes
If Yes, date Started:
If Yes, date Ended:
Improvement with therapy: No Yes

Treated with ribavirin: No Yes
If Yes, date Started:
If Yes, date Ended:
Improvement with therapy: No Yes

Other Therapy:

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Questions or comments? E-mail the Webmaster

Please be aware that medical advice, diagnoses and physician references cannot be obtained from this site.

See also: Clinical Trials Registry

See also: Scientific Models and Resources Registry

HEPC Registry: Follow-up Record

Copyright © 2001 CenterSpan

This site developed and maintained by SLACK Incorporated Questions or comments? E-mail the Webmaster

See also:
Clinical
Trials Registry

See also:
Scientific Models and
Resources Registry

This site developed and maintained by SLACK Incorporated
Questions or comments? E-mail the Webmaster