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RETRANSPLANTATION FORM
NIDDK Liver Transplantation Database



PATIENT ID  ________________________ ID
     


  1.  Retransplantation Date: ____/____/___ RXM   RXD   RXY 
                                  MM   DD   YY

  2.  Location:   ___ Center___ Other RXLOC (RX_LOC)

  3.  Biopsy slide of explant available:  ___ Yes     ___ No  BXEXP (YN)
      
  4.  Reason for retransplantation (select primary reason):RXRSN (RX_RSN) 

     ___ 4.1  Hepatic failure 
     ___ 4.2  Hepatocellular failure - ischemia (HAT/PVT)
     ___ 4.3  Hepatic failure-rejection:  acute____  chronic____ RHFAC
                                                                (ACUTEC)
     ___ 4.4  Chronic cholangitis
     ___ 4.5  Biliary strictures/abscesses
     ___ 4.6  Central venous sclerosis
     ___ 4.7  Recurrent disease: _____ RREC  Record liver disease code as provided on the back page,and specify if required: 
          ___________________________ RRECS
                  (30 characters)
     ___ 4.8  Other reason, specify: __________________________________ ROTHS
                                      (30 characters)
     ___ 4.9  Not documented


COMPLETION LOG

    Data Collector ID _____-_________  DCID
                    Center  Initials
    Data Collection Date ____/____/____ DCCM DCCD DCCYLTD
                         MM   DD   YY


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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.)