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LB

LONG-TERM FOLLOW-UP FORM
NIDDK Liver Transplantation Database
PATIENT ID _________-________________________ ID
SYSID       _______SYSID
EVALUATION TIMEPOINT __________ ETMPT
LAST CONTACT DATE:  LCM/LCD/LCY
                   

SKIP THIS SECTION IF DATA WILL BE TRANSFERRED ELECTRONICALLY

X.   LABORATORY DATA  (most recent result since last evaluation):
1.  CLINICAL CHEMISTRY                               Date of Sample            Not Done
                               Result               (MM/DD/YY)          (check enter -2)

Required tests
1.1    Total bilirubin       __ __ . __  mg/dl TBILI  ___/___/___  TBILM/TBILD/TBILY ____
1.2    Direct bilirubin     __ __ . __  mg/dl  DBILI  ___/___/___  DBILM/DBILD/DBILY ____
1.3    Alkaline phosphatase      _ __ __  U/L  AP     ___/___/___  APM/APD/APY       ____
1.4    SGOT (AST)          __ __ __ __ __  U/L SGOT   ___/___/___  SGOTM/SGOTD/SGOTY ____
1.5    SGPT (ALT)         __ __ __ __ __  U/L  SGPT   ___/___/___  SGPTM/SGPTD/SGPTY ____
1.6    Gamma GTP            __ __ __ __   U/L  GGTP   ___/___/___  GGTPM/GGTPD/GGTPY ____
1.7    Creatinine          __ __ . __    mg/dl CREAT  ___/___/___  CREAM/CREAD/CREAY ____
1.8    Blood urea nitrogen __ __ __ . __ mg/dl BUN    ___/___/___  BUNM/BUND/BUNY    ____
1.9    Albumin                    __.__  g/dl  ALB    ___/___/___   ALBM/ALBD/ALBY   ____
1.10  Blood alcohol level        __ __.__  mg% BAL    ___/___/___  BALM/BALD/BALY    ____
1.11  Prothrombin time (PT)      __ __.__ PTP /__ __.__ PTC secs.   ___/___/___  PTM/PTD/PTY   ____
1.12  Partial thromboplastin
    time (PTT)  __ __ __._ PTTP _/__ __ __.__ PTTC secs.___/___/___ PTTM/PTTD/PTTY   ____
                                          Patient /Control

One-time tests (to be done between years 7 ? 11 post-tx)

1.13  Alpha feto-protein__ __ __ __ __  ng/ml  AFP   ___/___/___  AFPM/AFPD/AFPY    ____
1.14  Total cholesterol  __ __ __ __    mg/dl  TCHL  ___/___/___  TCHLM/TCHLD/TCHLY ____
1.15  HDL                  __ __ __ __  mg/dl  HDL   ___/___/___  HDLM/HDLD/HDLY    ____
1.16  LDL                  __ __ __ __  mg/dl  LDL   ___/___/___  LDLM/LDLD/LDLY    ____
1.17  Triglycerides (fasting) __ __ __  mg/dl  TRIG  ___/___/___  TRIGM/TRIGD/TRIGY ____
1.18  Glucose (fasting)    __ __ __ __  mg/dl  GLU   ___/___/___  GLUM/GLUD/GLUY    ____
1.19  Glycosylated 
           hemoglobin      _ __ . __  % total  GHGB  ___/___/___  GHGBM/GHGBD/GHGBY ____
1.20  Serum iron            __ __ __ __  g/dl  SFE   ___/___/___  SFEM/SFED/SFEY    ____
1.21  Serum ferritin   __ __ __ __ __   ng/ml  SFERR ___/___/___  SFERM/SFERD/SFERY ____
1.22  Uric acid         __ __ __ . __   mg/dl  UA    ___/___/___  UAM/UAD/UAY       ____
1.23  GFR                    __ __ __  ml/min  GFR   ___/___/___  GFRM/GFRD/GFRY    ____
1.24  Creatinine clearance    __ __ __  ml/min CC    ___/___/___  CCM/CCD/CCY       ____


2.  INFECTION SCREEN (most recent result since last evaluation):
                                                                         Date of Sample         Not Done
            Pos  Neg                 (MM/DD/YY)       (-2)
           (POSNEG)

2.1    Anti-HAV IgM              ___  ___   HAVMR     ___/___/___  HAVMM/HAVMD/HAVMY ____
2.2    HBsAg                     ___  ___   HBSAR     ___/___/___  HBSAM/HBSAD/HBSAY ____
  2.2.1 HBV  DNA ___  ___   HBVR  level _____   HBVRL ___/___/___  HBVM/HBVD/HBVY    ____

IF HBsAg POSITIVE
*****************************************************************************
2.3    Anti-HBc IgM  ___  ___   HBCMR    ___/___/___    HBCMM/HBCMD/HBCMY   ____
2.4    HBeAg        ___  ___    HBER     ___/___/___   HBEM/HBED/HBEY       ____
2.5    Anti-HBe      ___  ___   AHBER    ___/___/___   AHBEM/AHBED/AHBEY    ____
2.6    Anti-HDV      ___  ___   HDVR     __/___/___   HDVM/HDVD/HDVY        ____
*****************************************************************************

2.7    Anti-HBc      ___  ___    HBCR     ___/___/___   HBCM/HBCD/HBCY    ____
2.8    Anti-HBs      ___  ___    HBSR     ___/___/___   HBSM/HBSD/HBSY    ____
2.9    Anti-HCV      ___  ___   HCVR      ___/___/___   HCVM/HCVD/HCVY    ____
  2.9.1 HCV  RIBA    ___  ___  RIBA  indet. ____        ___/___/___  RIBAM/RIBAD/RIBAY____
  2.9.2 HCV  RNA (PCR)  ___  ___ PCR  level _____ PCRL  ___/___/___  PCRM/PCRD/PCRY   ____

2.10  Anti-EBV (VCA) IgG    ___  ___  EBVGR       ___/___/___   EBVGM/EBVGD/EBVGY ____
2.11  Anti-EBV (VCA) IgM    ___  ___   EBVMR      ___/___/___   EBVMM/EBVMD/EBVMY ____
2.12  Anti-CMV IgG        ___  ___  CMVGR titer _____  CMVGT 
                                                  ___/___/___ CMVGM/CMVGD/CMVGY____

2.13  Anti-CMV IgM  ___  ___   CMVMR      ___/___/___  CMVMM/CMVMD/CMVMY ____

3.  IMMUNOLOGY
3.1  Antinuclear antibody    __  ___  ANA titer _____ ANAT  ___/___/___ ANAM/ANAD/ANAY    ____
3.2  Anti-mitochondrial antibody  ___ AMA titer _____ AMAT  __/___/___ AMAM/AMAD/AMAY    ____
3.3  AMA  - M2 subtype   ___ ___  AMAM2 titer _____ AMAMT___/___/___ AMAMM/AMAMD/AMAMY ____
3.4  SMA                    ___ __ SMA  titer _____ SMAT  ___/___/___  SMAM/SMAD/SMAY   ____
3.5  Anti-LKM               ______ LKM  titer _____ LKMT  ___/___/___  LKMM/LKMD/LKMY   ____

DATA COLLECTOR INITIALS:   DCID

DATA ENTRY USE ONLY
Data Entry   ___/___/___  DCCM/DCCD/DCCY
    Sysid    __________ SYSID
Verification ___/___/___
Cleaned      ___/___/___
Transfer     ___/___/___
             MM/DD/YY