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PP NIDDK Liver Transplantation Database POST-TRANSPLANT - PATHOLOGY HISTOLOGY FINDINGS 02/12/1991 FORM KEYS Patient ID __________________________ ID Transplant No. ________ NTX Date of Specimen _____/_____/_____ DOSM/DOSD/DOSY MM DD YY COMPLETION LOG Data Collector ID ________-______________DCID Center Initials DATE Data Collection _____/_____/_____ DCCM/DCCD/DCCY Data Entry _____/_____/_____ Sysid _____ SYSID Verification _____/_____/_____ Cleaned _____/_____/_____ Transfer _____/_____/_____ MM DD YY ******************************************************************************************** PP POST-TRANSPLANT - PATHOLOGY HISTOLOGY FINDINGS NIDDK Liver Transplantation Database SURGICAL # _________-_________________________ PATIENT ID _________-_________________________ ID TRANSPLANT NO. ______ NTX DATE OF SPECIMEN _____/_____/_____ DOSM/DOSD/DOSY --- DOF MM DD YY Pages 1-4 to be completed by PATHOLOGIST. In the case of a failed allograft or autopsy, the PG Form must also be completed by the Pathologist. I. SOURCE OF SPECIMEN (check one): 1. Biopsy__ 2. Failed allograft__ 3. Autopsy__ SOURC (SOURCE) II. HISTOLOGICAL EVALUATION 1. Are there more than 4 portal tracts? Yes__ No__ M4PT (YN) 2. Is specimen otherwise considered adequate? Yes__ No__ SADEQ (YN) 3. PORTAL TRACT (check one under each category) 3.1 Overall inflammation intensity: 1. None__ 2. Mild__ 3. Moderate__ 4. Severe__ PTII (SSCALE) 3.2 Bile duct inflammation/damage: Yes__ No__ BDID (YN) 3.3 Bile duct loss: Yes__ No__ Not evaluable__ BDL (YNNE) IF YES 3.3.1 Number of portal tracts without ducts ______ PTWOD 3.3.2 Total number of portal tracts ______ TNPT 3.4 Bile duct/cholangiolar proliferation (in any portal tract): Yes__ No__ BDCP (YN) 4. INFLAMMATORY or NECROTIZING ARTERITIS: Yes__ No__ INART (YN) 5. OBLITERATIVE ARTERIOPATHY: Yes__ No__ OBLAR (YN) 6. ENDOTHELIITIS/SUBENDOTHELIAL INFLAMMATION: Yes__ No__ ESINF (YN) 7. FIBROSIS: (check one under each category) 7.1 Portal: 1. None__ 2. Mild__ 3. Moderate__ 4. Severe (Bridging)__ PFIB (SSCALE) 7.2 Central: 1. None__ 2. Mild__ 3. Moderate__ 4. Severe (Bridging)__ CFIB (SSCALE) 8. LOBULAR DISARRAY/BALLOONING (check one): 1. None__ 2. Mild__ 3. Moderate__ 4. Severe__ LODB (SSCALE) 9. NECROSIS (check one under each category): 9.1 Piecemeal or bridging: Yes__ No__ PBNEC (YN) 9.2 Hilum of the liver (duct walls, connective tissue): Yes__ No__ NA__ HNEC (YNNA) 9.3 Infarct (ischemic necrosis): Yes__ No__ NA__ INEC (YNNA) 9.4 Other necrosis: Yes__ No__ ONEC (YN) 9.5 Central lobular: Yes__ No__ CLOB (YN) 10. CHOLESTASIS: Yes__ No__ CHOL (YN) 11. FAT: (check one) 1. None__ 2. Mild__ 3. Moderate__ 4. Severe__ FAT (SSCALE) 12. LOBULAR INFLAMMATION (check one under each category): 12.1 Severity: 1. None__ 2. Mild__ 3. Moderate__ 4. Severe__ SLI (SSCALE) 12.2 Granulomatous: Yes__ No__ GLI (YN) III. PATHOLOGIC DIAGNOSIS(ES) - based on Histological Evaluation See ADDITIONAL DIAGNOSIS on page 4 of PG Form for diagnosis on failed grafts and autopsies if these are insufficient. Rank all that apply in order of importance, #1 being most important, #2 as next most important, etc. 1. BILIARY TRACT (probably not related to rejection) BTDOC __ 1.1 Suggestive of duct obstruction/cholangitis OBTD __ 1.2 Other OBTDT _____________________________________________ specify (30 char) 2. ISCHEMIC INJURY ISINJ __ 2.1 Ischemic injury present IF PRESENT 2.1.1 Was there an infarct? Yes__ No__ ISINI (YN) PRES __ 2.2 Preservation injury 3. VIRAL HEPATITIS PVHEP __ 3.1 Possibly/probably viral 1. Acute__ 2. Chronic persistent__ 3. Chronic active__ VHS1 (TYPE) DVHEP __ 3.2 Definitely viral hepatitis 1. Acute__ 2. Chronic persistent__ 3. Chronic active__ VHS2 (TYPE) Check appropriate virus, based on morphology (without special stains) See Appendix I of Operations Manual for Technical Information DVHAD __ 1. Adenovirus (YN) DVHCM __ 2. CMV DVHEB __ 3. EBV DVHHE __ 4. Herpes DVHTB __ 5. Type B DVHOT __ 6. Other DVHOO __________________________________________________ specify (30 char) 4. REJECTION HHR __ 4.1 Consistent with humoral related rejection CWACR __ 4.2 Consistent with, but not diagnostic of, acute cellular rejection ACREJ __ 4.3 Acute cellular rejection RACR __ 4.4 Resolving acute cellular rejection CVREJ __ 4.5 Consistent with chronic vascular rejection VBDS __ 4.6 Consistent with vanishing bile duct syndrome (if > 50% duct loss; see 3.3 on p.1) 5. OTHER ENOTH __ 5.1 Essentially normal SEPS __ 5.2 Sepsis RPDIS __ 5.3 Recurrent primary disease RPDSS __________________________________________ specify (30 char) PRD __ 5.4 Possible recurrent disease NSCCN __ 5.5 Non-specific changes/cholestasis, NOS PDR __ 5.6 Possible drug reaction ODX __ 5.7 Other ODXS _______________________________________________ specify (30 char) To be completed by Clinical Coordinator after the pathologist completes I-III. IV. 1. REASON FOR EVALUATION (check one) RFEVA __ 1. Protocol biopsy __ 2. Complication (suspected) __ 3. Failed allograft (retransplant) __ 4. Autopsy IF PROTOCOL BIOPSY Check timepoint (check one): PTMPT (PTMPT) __ 1. Day 0/day 1 __ 6. Week 4 __11. Year 2 __ 2. Day 3 __ 7. Week 5 __12. Year 3 __ 3. Week 1 __ 8. Week 6 __13. Year 4 __ 4. Week 2 __ 9. Month 4 __14. Year 5 __ 5. Week 3 __10. Year 1 __15. Other 2. WAS THIS SPECIMEN A BIOPSY? Yes__ No__ SBX (YN) IF YES 2.1 TYPE OF SPECIMEN (check one): TYSPE (SPEC2) __ 1. Needle biopsy __ 2. Wedge biopsy __ 3. Other TYSPO _____________________________________________ specify (30 char) 2.2 ROUTE OF BIOPSY (check one): BXRT (ROUTE) __ 1. Intercostal __ 2. Subcostal __ 3. Transjugular __ 4. Operative __ 5. Other BXORT _____________________________________________ specify (30 char) 2.3 Was there a COMPLICATION of liver biopsy? Yes__ No__ BXCOM (YN) IF YES 2.3.1 Check all that apply: HYPO __ 2.3.1.1 Hypotension (< 90/60) (YN) BRADY __ 2.3.1.2 Bradycardia (< 60 beats/min) FIHGB __ 2.3.1.3 Fall in HGB > 2 gm HEMAT __ 2.3.1.4 Hematobilia BOWEL __ 2.3.1.5 Bowel perforation INFEC __ 2.3.1.6 Infection occurred DEATH __ 2.3.1.7 Death OCOMP __ 2.3.1.8 Other _ OCOMS ___________________ specify (30 char) 2.3.2 Were any of the following required? (check as appropriate) TRANF __ 2.3.2.1 Transfusion OPERA __ 2.3.2.2 Operation HOSP __ 2.3.2.3 Hospitalization V. COMMENTS: Yes__ No__ COMM (YN) IF YES COM1 TEXT COM2 TEXT COM3 TEXT COM4 TEXT COM5 TEXT COM6 TEXT COM7 TEXT COM8 TEXT COM9 TEXT VI. REJECTION GRADE _______ REJD (REJD) PATID VII. PATHOLOGIST ID ________ - _____________ 2 Digit 3 letter Center Initials Code