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					                                  CTS COLLABORATIVE TRANSPLANT STUDY
                                                                          LIVER TRANSPLANT
Transplant Center

                                                                                                                             Viral Status:        HCV        pos         neg
                    Name (Last, First) or ID                          Age             Sex         Race           AB0                              HBV        pos         neg
                                                                                                                                                  EBV        pos         neg
HLA-Typing                    ,                       ,                        ,                      ,                      ,                    CMV        pos         neg
                            A                         B                     DRB                     DQA                     DQB
                                                                                                                                                  CMV prophylaxis
Pretransplant Antibodies                       Solid Phase Assay (latest serum)                                                                     yes
Lymphocytotoxicity                                                                                                                                  no    Type, Manufacturer
                                                Class I neg pos % panel
               Latest serum                     ELISA
                                                                                                    Does this patient have a history of smoking?                 yes       no
T cells or unsep:            % pos
                                                                                                                                   Currently smoking?            yes       no
B cells:                     % pos              Class II    neg pos % panel
                                                                                                 Does this patient receive treatment for diabetes?               yes       no
sCD30 level:                 units/mL                                                       Is patient on antihypertensive drugs(excl diuretics)?                yes       no
                                                                                                                        Immunosuppressive Protocol
MELD score:                  (PELD for pediatrics)                                                                               (intention to treat)

Pretransplant Blood Transfusions:                                No. units ever given                        Cyclosporine                       Tacrolimus
                                                                                                                Optoral/Neoral                      Prograf
Original Disease                                                          Your general                          Generic                             Advagraf
   Cirrhosis                        Biliary Atresia                       evaluation of this                 Azathioprine                           Generic
                                                                          patient as candidate
       primary biliary              Fulminant Hepatitis                                                      Everolimus/Certican                Mycophenolate (MPA)
                                                                          for transplantation:
       cryptogenic                                                                                           Sirolimus/Rapamycin                   CellCept
                                    Acute Hepatic Failure                    good
       alcoholic                                                                                                                                   Myfortic
       Hepatitis B                                                           moderate                                                              Generic
                                    Tumor                                    poor                            IL2R-antibody induction
       Hepatitis C
       Chronic Active Hep.                                                                                   ATG prophylactic:
       Autoimmune                                                         If moderate or poor,                                                ATG Manufacturer
       Other                                          specify
                                                                          indicate reason(s):            Other monoclonal antibody:
                 specify                                                     Urgency                     Other Immunosuppression:
                                    Other                                    Other
   Sclerosing Cholangitis                                                                                Patient is enrolled in immunosuppressive trial
                                                  specify                              specify

TRANSPLANT Transplant Date                       Donor (Relationship)              Graft No.      Urgency                Graft Size            If not full size
                                                   Deceased                          First          Super urgent            Full size              Left lobe (Seg 2-3)
                                                   Parent                            Second         Urgent                  Reduced size           Left liver (Seg 2-4)
                     Day Month Year                Sibling                           Third          Normal                  Split liver            Right liver (Seg 5-8)
                                                   Other                                                                                           Other
                                                                specify            If Retransplant                Special Technique                            specify
                                                                                   Number days previous              Auxiliary                 Combined tx
                                                                                   graft functioned                  Heterotopic                 Kidney + liver tx
                                                                                                                                  specify                     other
Crossmatch results (latest pretransplant serum)
Indicate results obtained with + (pos) or – (neg), leave rest blank                                            Indicate where relevant:
Whole                                   B cells                                                                Autologous X-match
Lymphocytes         T cells             (unabsorbed)                                                           against recipient cells              DTT
22°                 37° or 22°          37° or 22°      5°          Flow                     ELISA             T37/22 B37/22 B5                     X-match

DONOR                                                                                                                             Viral Status:     HCV       pos         neg
                    Name (Initials) or ID                           Age             Sex           Race          AB0
                                                                                                                                                    HBV       pos         neg
                                                                                                                                                    EBV       pos         neg
HLA-Typing                   ,                        ,                        ,                         ,                    ,                     CMV       pos         neg
                            A                         B                     DRB                     DQA                     DQB

Donor Death                       Treated with                   Macrovesicular Steatosis                       Preservation                       Cold Ischemia
   Trauma                            Dopamine                    Donor history of hypertension                     UW Solution                     (hours)
   Cerebrovascular                   Noradrenalin                Marginal donor for                                HTK
   Other                             no treatment                other reason                                      Celsior
               specify                                                                                             Other
                                                                 Non-heartbeating donor                                            specify

                                                                                                                             Mail to: Transplantation Immunology
                                                                                                                                      Im Neuenheimer Feld 305
Date                                  Signature                                                                                       D-69120 Heidelberg · Germany

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