Persons using assistive technology may not be able to fully access information in this file. For assistance, e-mail niddk-cr@imsweb.com. Include the Web site and filename in your message. MD NIDDK Liver Transplantation Database DEATH REPORT FORM 04/12/1999 FORM KEYS Patient ID ____________________________ ID COMPLETION LOG Data Collector ID ________-______________ DCID Center Iniitials DATE Data Collection _____/_____/_____ DCCM DCCD DCCY Data Entry _____/_____/_____ Sysid _____ Verification _____/_____/_____ Cleaned _____/_____/_____ Transfer _____/_____/_____ MM DD YY **************************************************************************************************************** MD DEATH REPORT FORM NIDDK Liver Transplantation Database PATIENT ID _________-____________________ ID I. 1. DATE OF DEATH _____/_____/_____ DODM DODD DODY MM DD YY 2. TIME OF DEATH ____:____ (military time) TOD hrs min II. AUTOPSY Yes__ No__ Unk__ AUTOP TSTAT IF YES 1. Hospital __________________________________________ AUTOH specify (30 char) 2. Type of autopsy (check one) AUTOT (ATYPE) __ 1. Whole body __ 2. Limited ______________________________________ AUTOS specify (30 char) III. TRANSPLANT STATUS (check one) TSTAT (TXSTAT) __ 1. Post-transplant __ 2. Intraoperative, during repeat transplant IF INTRAOPERATIVE 2.1 Patient received a transplant? Yes__ No__ TXREC IF NO 2.1.1 Specify reason____________________________ TXNOT (30 char) IF YES 2.1.2 Status of new graft (check one) GSTAT (GSTAT) __ 1. Non functioning __ 2. Poor function 2.1.3 Did graft functioning contribute to death? Yes__ No__ GFUNC 2.1.4 Did graft technical complications contribute to death? Yes__ No__ GTECH 2.1.5 Length of time out of hospital since most recent transplant (check one) TIMEO (TIMET) __ 1. Never discharged __ 4. 7-9 months __ 2. < 3 months __ 5. 10-12 months __ 3. 3-6 months __ 6. > 12 months IV. CAUSE OF DEATH 1. Major cause: record code from list below ______ CDTH (DCAUSE) specify, if required __________________________________________ CDTHS (30 char) IF RECURRENT DISEASE, provide liver disease code from opposite page ____ CDRLD (LIVER) specify, if required __________________________________ CDRDS (30 char) 2. Associated/contributing conditions (check all that apply except do not check major cause): HEPATIC HEPF __ 1. Hepatic failure HEPCF __ 2. Hepatocellular failure-ischemia (HAT/PVT) HEPFR __ 3. Hepatic failure-rejection HEPEN __ 4. Hepatic encephalopathy CHOLA __ 5. Cholangitis RECURRENT DISEASE RECLD __6. Record liver disease code from opposite page ____ RLDDX (LIVER),and specify if required _____________________________ RLDDS (30 char) RENAL RENF __ 7. Renal failure ATN __ 8. Acute tubular necrosis ABDOMINAL PERFC __ 9. Perforated colon PERFU __ 10. Perforated peptic ulcer UGIB __ 11. Upper GI bleed GASTH __ 12. Gastritis hemorrhage LGIH __ 13. Lower gastrointestinal hemorrhage VARH __ 14. Variceal hemorrhage GIBUS __ 15. GI bleed-unknown source INFECTION BPERI __ 16. Bacterial peritonitis GSEP ___ 17. Generalized sepsis CMV __ 18. CMV OPINF __ 19. Opportunistic infection PNEU __ 20. Pneumonia MENIN __ 21. Meningitis MALIGNANCY METM __ 22. Metastatic malignancy, specify _______________________________ METMS (30 char) PRIMM __ 23. Primary malignancy, specify _______________________________ PRIMS (30 char) PTLD __ 24. PTLD OTHER RESPF __ 25. Respiratory failure/ARDS DIAB __ 26. Diabetes mellitus MI __ 27. Myocardial infarction CARAR __ 28. Cardiac arrest/Intra-operative death CVA __ 29. Cerebrovascular accident CERED __ 30. Cerebral edema CPM __ 31. Central pontine myelinolysis MSF __ 32. Multi-system failure MVA __ 33. Motor vehicle accident OTRAU __ 34. Other form of trauma SUIC __ 35. Suicide GVHD __ 36. Graft vs. host disease ODEAD __ 37. Other, specify ______________________________ ODEAS (30 char) UNK __ 38. Unknown V. COMMENTS: Yes__ No__ COMM IF YES, record any additional information pertaining to the death of the patient (60 char/line) COM1 COM2 COM3 COM4 COM5 COM6 COM7 COM8 COM9 COM10 LIVER DISEASE DIAGNOSES 1. Acute hepatitis A 2. Acute hepatitis B 3. Acute hepatitis B and D 4. Acute hepatitis C 5. Acute hepatitis other (specify: e.g. drug or toxin, presumed viral, CMV, EBV, etc.) 6. Acute hepatitis of unknown cause 7. Alcoholic liver disease (Laennec's cirrhosis) 8. Alpha-1-antitrypsin deficiency 9. Benign tumor (specify: e.g. adenoma) 10. Biliary atresia 11. Budd-Chiari syndrome 12. Chronic cholestatic syndrome of childhood (specify: e.g. Bylers, Alagilles, non-syndromatic paucity of bile ducts, etc.) 13. Chronic autoimmune (lupoid) hepatitis/cirrhosis 14. Chronic hepatitis B/cirrhosis 15. Chronic hepatitis B and D/cirrhosis 16. Chronic hepatitis C/cirrhosis 17. Chronic hepatitis/cirrhosis other (specify: e.g. drug or toxin, presumed viral, etc.) 18. Chronic hepatitis/cirrhosis of unknown cause 19. Congenital biliary and fibrocystic disease (specify: e.g. congenital hepatic fibrosis, Caroli's disease, polycystic liver disease, choledochal cyst, etc.) 20. Glycogen storage disease (specify type) 21. Hemochromatosis 22. Homozygous hypercholesterolemia 23. Hyperalimentation-induced liver disease 24. Malignancy, cholangiocarcinoma 25. Malignancy, fibrolamellar hepatocellular carcinoma 26. Malignancy, hepatocellular carcinoma 27. Malignancy, other (specify: e.g. angiosarcoma, hemangioendothelioma, hepatoblastoma, etc.) 28. Metastatic malignancy (specify: e.g. carcinoma of breast, colon, lung, etc.) 29. Neonatal or pediatric post-hepatitic cirrhosis 30. Primary biliary cirrhosis 31. Primary sclerosing cholangitis 32. Secondary biliary cirrhosis (specify cause: e.g. gall stones, stricture, etc.) 33. Tyrosinemia 34. Wilson's disease 35. Other (specify: e.g. trauma, cystic fibrosis, etc.)