THIS SECTION FOR ALL PATIENTS DIALYSED AT ANY TIME DURING THIS SURVEY See instructions on the back of the form AUS. & N.Z. AND TRANSPLANT SURVEY PERIOD

THIS SECTION FOR ALL PATIENTS 19 TYPE OF 20 DRY WEIGHT 21 UNCORRECTED 22 PHOSPHATE 23 HAEMOGLOBIN 24 EPO AGENT 25 FERRITIN 26 % SATURATION IRON DIALYSIS AT LAST DX CALCIUM (Transferrin Saturation) REGISTRY NUMBER INITIAL HOSPITAL CURRENT PARENT HOSPITAL g/l ug/l Hospital / State Hospital Unit No. Hospital / State Hospital Unit No. Physician kg mmol/l mmol/l (see list) HD and PD Patients Last Available Y=Yes N=No Within last 3 months of Survey or record not done

3 DATE OF BIRTH 4 GENDER HAEMODIALYSIS Surname Given Names 27 DIALYSER BRAND (Write In) 28 BLOOD 29 SESSIONS 30 HOURS 31 REDUCTION or Kt/V FLOW RATE PER WEEK PER SESSION CODE BRAND NAME AND MODEL Method Value 6 PRIMARY RENAL DISEASE (Record from list) 7 BIOPSY 8 SE.CREATININE 5 ETHNICITY (Record from list) Pump Speed OTHER - OTHER - Y / N mls/min See List 9 COUNTRY OF BIRTH (If Australia or NZ - Tick box) 10 POSTCODE AT ENTRY POSTCODE AT END SURVEY 32 ACCESS IN USE (Functioning only) AUST NZ OTHER COUNTRY (Please specify) AT FIRST HD 1-Native AT LAST HD 2=Synthetic PLEASE COMPLETE SECTIONS 19-58 INCLUSIVE, ACCORDING TO THE TREATMENT 11 CO-MORBID CONDITIONS AT ENTRY 3=Tunnel CV Catheter UNDERTAKEN BY THE PATIENT. COMPLETE ALL RELEVANT SECTIONS IN THE EVENT OF 4=Non Tunnel CV THE PATIENT HAVING MORE THAN ONE TREATMENT IN THE SURVEY PERIOD. LATE REFERRAL HEIGHT (cms) WEIGHT (kg) CIGARETTE SMOKING Catheter Once only entry <3 MONTHS BEFORE N=Never ALL PERITONEAL DIALYSIS FIRST TREATMENT F=Former (Y/N) C=Current 33 PET TEST (Once only) 34 CONNECTION SYSTEM 35 PERITONITIS 36 NUMBER OF EPISODES OF 37 TOTAL VOLUME OF Within first 6 mths CODE (Write In) DATE OF FIRST EPISODE PERITONITIS DURING SURVEY WEEKLY EXCHANGES DIABETES DISEASE AT ENTRY AND DURING CURRENT SURVEY N=No Dx/Plasma Creatinine O=Type 1 - Insulin dependent DM at 4 hours Y=Yes N=No CHRONIC CORONARY PERIPHERAL CEREBRO P=Type 2 - Non-Insulin requiring DM S=Suspected LUNG (Y/S/N) ARTERY (Y/S/N) VASCULAR (Y/S/N) VASCULAR (Y/S/N) Q=Type 2 - Insulin requiring DM 38 CREATININE 39 DIALYSATE ONLY 40 RESIDUAL RENAL FUNCTION 41 PD SOLUTIONS - Y=Yes N=No (Creatinine Clearance) (Please fill in all boxes) AT ENTRY Dialysate ONLY WEEKLY Kt/V LAST Adjusted for Body Adjusted for body Other Surface Area Surface Area CURRENT Litres/week/1.73m² Range 0.1 - 5.0 Litres/week/1.73m² Glucose Icodextrin Low GDP *** *** *** *** *** Range 10-200 Litres/Week OTHER CO-MORBID CONDITIONS (Write in) AT ENTRY OR CURRENT GRAFT (IN THE EVENT OF BOTH GRAFT FAILURE AND RETRANSPLANT IN THIS SURVEY - USE A NEW FORM) PREVIOUS SURVEYS 42 GRAFT 43 DATE OF THIS 44 REFERRING 45 DONOR 46 TRANSPLANT 47 RECIPIENT ANTIBODY 48 NUMBER OF REJECTION NUMBER TRANSPLANT HOSPITAL HOSPITAL HOSPITAL STATUS AT GRAFT EPISODES THIS SURVEY CURRENT CMV EBV (Complete acute rejection 12 CENTRE OF TREATMENT HOSPITAL / CENTRE NAME (Write in or tick if same) CENTRE CODE DATE TRANSFER 1=Positive 2=Negative form for each episode at Enter geographical CURRENT 3=Not done any time during the location at Death or End survey) of Survey LAST 49 DONOR DETAILS 50 TOTAL 51 IMMEDIATE 52 DISEASE IN 53 DATE FIRST PROVEN 54 GRAFT FAILURE Serum Creatinine SOURCE AGE SEX ISCHAEMIA FUNCTION GRAFT (eg. Graft biopsy) Cause (Record from list) at Graft Failure

OTHER - 14 HEPATITIS C ANTIBODY (Hours) (See list) (See list)

REASON FOR DIALYSIS MODALITY CHANGE from - 1=Positive CURRENT LAST 55 MONOCLONAL / POLYCLONAL THERAPY (Record from list) CAPD to APD / APD to CAPD / Any PD to HD / HD to any PD 2=Negative Enter Reason for Change FROM Previous Modality TO Current Modality - Refer to codes on back of form 3=Not done COURSE DATE AGENT OTHER NO OF DOSES GIVEN REASON OTHER 13 COURSE OF TREATMENT SEQ SEQ SEQ 1st No No No COMPLETE ACCORDING TO CODE CODE DAY MTH YR REASON CODE DAY MTH YR REASON CODE DAY MTH YR REASON

E APD / IPD 1 16 31 M CAPD 2 17 32 56 TOTAL DAILY DRUG DOSE (mg) BC HD Hospital-Conventional 3 18 33 TOTAL INITIAL DC HD Satellite-Conventional ORAL DOSE 1 Mth 2 Mth 3 Mth 6 Mth 1 Yr 2 Yr 3 Yr 5 Yr 7 Yr 10 Yr 15 Yr 20 Yr 25 Yr 30 Yr 35 Yr 40 Yr 45 Yr 50 Yr FC HD Home-Conventional 4 19 34 BQ HD Hospital-Quotidian AZA DQ HD Satellite-Quotidian 5 20 35 CYA FQ HD Home-Quotidian 6 21 36 PRED G Transplant in AUST/NZ MMF H Date of last post graft dialysis 7 22 37 X Transplant Overseas MPA 8 23 38 T Graft function ceased - Temporary SIROL P Graft function ceased - Permanent 9 24 39 TACROL J Own kidney function recovered. 10 25 40 Dialysis ceased K Date of last visit if lost to 11 26 41 follow up 12 27 42 Z Date of Death 57 BODY WEIGHT (kg) 13 28 43

14 29 44 58 SERUM CREATININE 15 30 45 (umol/L)

15 CANCER EVER? (Y/N) 16 CAUSE OF DEATH (Record from list) 17 WAS GRAFT SUSTAINING LIFE? 18 PARENTHOOD DATE OF LAST OUTCOME If Yes, enter separate Without dialysis at time of Has this patient become pregnant or Y=Yes If Yes, please complete the Pregnancy Cancer Form death Y=Yes N=No fathered a child during this survey N=No Outcome form 5 - ETHNICITY PRIMARY RENAL DISEASE Continued... CAUSE OF DEATH continued... 33 - PET TEST (Required once only per patient) 52 - DISEASE IN GRAFT (Histologically proven) 0000 Response Unidentifiable 007 Cortical Necrosis Standard Peritoneal Dialysis Equilibration Test Complete this section for FUNCTIONING or FAILED GRAFTS 0001 Not Stated performed 1-6 months after initiation of PD. (2.5% 2 008 Interstitial Nephritis INFECTION B BK Virus Nephropathy in Graft 1101 Oceanian - Australian litre exchanges) 009 Congenital Renal Hypoplasia and Dysplasia Please enter code for nature of infective organism, Y Disease Recurrence - Primary Renal Disease and Disease in 1102 Oceanian - Australian Aboriginal Provide dialysis/plasma creatinine at 4 hours. 010 Loss of Single Kidney (Trauma-Surgery) after the code for site of infection. Please specify Range 0.1-1.2 Graft the same 1103 Oceanian - Australian South Sea Islander 011 Megaureter type of organism. eg. Staph, CMV, Candida, etc. D De Novo Glomerulonephritis - Primary Renal Disease Known 1104 Oceanian - Torres Strait Islander 012 Oxalosis e.g. 321 Lung infection - bacterial (staph) and not the Same 38 - 40 - PD CLEARANCE STUDIES 1201 Oceanian - New Zealand Maori 013 Cystinosis 322 Lung infection - viral (CMV) G Glomerulonephritis in Graft - Primary Renal Disease Generated from a 24 hour collection of PD effluent 1202 Oceanian - New Zealand European 014 Balkan Nephropathy 31 CNS 1 Bacterial Unknown or Not Biopsied 32 Lung 2 Viral and . 1300 Oceanian - Melanesian And Papuan (Specify) 015 Renal Cell Carcinoma (GRAWITZ) In cases of glomerulonephritis, where histological confirmation of 33 Urinary tract 3 Fungal NOTE: Dialysate Creatinine Clearances and Kt/V both 1400 Oceanian - Micronesian (Specify) 016 Transitional Cell Carcinoma Urinary Tract recurrence may be uncertain, enter as G. 34 Wound 4 Protozoa refer to dialysis clearances ONLY (NOT the total of 1500 Oceanian - Polynesian (Specify) 017 Paraproteinaemia (Including Multiple Myeloma) dialysis and renal clearances). 35 Shunt 5 Other 54 - CAUSE OF GRAFT FAILURE 1501 Cook Islander 018 Light Chain Nephropathy (Not Malignant) 36 Peritoneum 1502 Fijian 019 Lithium Toxicity 37 Septicaemia - site unknown (specify organism) 38 CREATININE CLEARANCE (Dialysate only) REJECTION 1503 Niuean 020 Post Partum Nephropathy 38 Liver (incl. viral Hepatitis) (specify A, B, CMV, Range 10-200 litres/week 10 Hyperacute Rejection (within 48 Hrs of Transplantation) 1504 Samoan 021 Sarcoidosis herpes,etc) Litres/week/1.73m² Body Surface Area 20 Acute Rejection at anytime Causing Graft Failure 1505 Tongan 031 Posterior Urethral Valves 39 Other site (specify) 1508 Tokelauan 032 Pelvi-Ureteric Junction Obstruction 39 DIALYSATE WEEKLY Kt/V - Range 0.1 - 5.0 40 Chronic Allograft Nephropathy (Slow Progressive Loss of Function) 2000 North-West European (Specify) 033 Obstructed Megaureter SOCIAL 034 Neuropathic Bladder 40 RESIDUAL RENAL CLEARANCE 3000 Southern and Eastern European (Specify) 40 Withdrawal-Psycho Social Reasons VASCULAR (Creatinine Clearance) 3103 Southern and Eastern European - Italian 035 Non-Obstructed Dilated Bladder (Megacystitis- 41 Patient Refused Treatment (Specify) Litres/week/1.73m² Body Surface Area 3205 Southern and Eastern European - Greek Megaureter) 42 Suicide 50 Renal Artery Stenosis 036 Spina Bifida or Myelomeningocoele 4000 North African and Middle Eastern (Specify) 43 Therapy Ceased Other Reasons (Specify) 51 Renal Artery Thrombosis 037 Bladder Neck Obstruction (incl. Prostatiomegaly) 4100 North African and Middle Eastern - Arab (Specify) 44 Accidental Death (All Causes) Specify 52 Renal Vein Thrombosis 039 Other Lower Urinary Tract Abnormalities (with 49 - SOURCE OF DONOR KIDNEY 4907 North African and Middle Eastern - Turkish 45 Withdrawal-Cardiovascular Comorbid Conditions 53 Haemorrhage (Primary) Secondary Reflux) 100 Deceased 54 Haemorrhage (Secondary) 5000 South-East Asian (Specify) 040 Ureteric Obstructive Nephropathy 46 Withdrawal-Cerebrovascular Comorbid Conditions 200 Sister 55 Embolus - Thrombo 5107 South-East Asian - Vietnamese 041 Obstructive Nephropathy 47 Withdrawal-Peripheral Vascular Comorbid Conditions 201 Brother 56 Embolus - Cholesterol 5201 South-East Asian - Filipino 042 Calcineurin Inhibitor Toxicity 48 Withdrawal-Malignancy 5202 South-East Asian - Indonesian 49 Withdrawal-Dialysis Access Difficulties 202 Mother 57 Haemolytic Uraemic Syndrome 5205 South East Asian - Malay 13 - REASON FOR MODALITY CHANGE 203 Father From CAPD to APD TECHNICAL 6000 North - East Asian (Specify) MISCELLANEOUS 204 Monzygotic (Identical Twin Girl) From APD to CAPD 205 Monzygotic (Identical Twin Boy) 60 Non-Viable Kidney (Due To Pre-Transplant Cortical 6101 North - East Asian - Chinese From any form of PD to HD 50 Hepatic Failure (Specify) 7000 Southern and Central Asian (Specify) 51 Uraemia Caused by Graft Failure 206 Dizygotic (Non-Identical Twin Girl) Necrosis) From HD to any form of PD 61 Cortical Necrosis. Post Transplant (Not Due To 7100 Southern Asian, nfd 52 Pancreatitis 207 Dizygotic (Non-Identical Twin Boy) 10 Recurrent/Persistent Peritonitis 208 Daughter Rejection) 7106 Southern and Central Asian - Indian 53 Bone Marrow Depression 70 Ureteric and Bladder Problems 7200 Central Asian, nfd 11 Acute Peritonitis 54 Cachexia 209 Son 8100 North American (Specify) 15 Tunnel/Exit Site Infection 55 Unknown 210 Grandmother GLOMERULONEPHRITIS 8105 Hispanic North American 16 Diverticulitis 56 Malignant Disease 211 Grandfather 82 Mesangiocapillary GN with Subendothelial Deposits 8200 South American (Specify) 20 Inadequate Solute Clearance 57 Perforation Abdominal Viscus 212 Cousin 83 Mesangiocapillary GN with Intramembranous Deposits 8300 Central American (Specify) 21 Inadequate Fluid 58 Dialysis Dementia (Aluminium) 213 Niece (Dense Deposit Disease) 8400 Caribbean Islander (Specify) 22 Excessive Fluid Ultrafiltration 59 Other (Specify) 214 Nephew 84 Focal Sclerosing GN (Including Hyalinosis) 9000 Sub-Saharan African (Specify) 27 Abdominal Abscess 60 Immunodeficiency Due to Viral Infection (Specify) 215 Aunt 85 Membranous GN 9999 Other (Specify) 30 Dialysate Leak 61 Chronic Respiratory Failure 216 Uncle 86 Mesangial Proliferative (IgA Positive) 31 Catheter Block 62 Sclerosing Peritonitis 217 Other related (Genetically - specify) 87 Goodpastures Syndrome 6 - PRIMARY RENAL DISEASE 32 Haemoperitoneum 300 Wife 88 Intra and Extra Capillary GN (Clinically Rapidly 100 Presumed GN (No Biopsy) 33 Catheter Fell Out 19 - TYPE OF DIALYSIS 301 Husband Progressive) 110 Focal Sclerosing GN (Including Hyalinosis) 89 Glomerulonephritis Other (Specify) 35 Hernia 12 Haemodialysis 302 Partner 111 Primary Focal Sclerosing GN or Focal Glomerular Sclerosis 36 Abdominal Pain 303 Fiance / Fiancee 15 Haemofiltration DRUG THERAPY 112 Secondary Focal Sclerosing GN 40 Abdominal Surgery 304 Mother-in-law 161 HDF-Predilution 121 Mesangiocapillary GN (Double Contour) 41 Sclerosing Peritonitis 305 Father-in-law 90 Complications of Drug Therapy Requiring Reduction or 122 Mesangiocapillary GN (Dense Deposit Disease) 43 Multiple Adhesions 162 HDF-Mixed-Dilution 306 Stepmother Withdrawal of Steroid and/or Immunosuppressants 130 Membranous GN 44 Pregnancy 163 HDF-Postdilution 307 Stepfather 91 Non Compliance with Therapy - Causing Graft Failure 140 Extra and Intra Capillary GN (Rapidly Progressive) 45 Haematuria 19 C.V.V.HD (Intensive Care Unit) 308 Stepsister 92 Rejection Following I/S Reduction Due to Malignancy 151 Mesangial Proliferative (Iga+) 46 Pleural Effusion 21 Peritoneal - Continuous Ambulatory (CAPD) 309 Stepbrother 93 Rejection Following I/S Reduction Due to Infection 152 Mesangial Proliferative (Iga-) 47 Cardiovascular 22 Peritoneal - Automated (APD) 310 Sister-in-law MISCELLANEOUS 153 Mesangial Proliferative (No If Studies) 48 Geography 311 Brother-in-law 00 Miscellaneous Other (Specify) 160 Focal and Segmental Proliferative GN 49 Vascular Access 20 - DRY WEIGHT 312 Daughter-in-law 01 Donor Malignancy 170 Advanced GN (Unclassified=End Stage) 50 Patient Preference At end of survey, prior to transplantation or death. 313 Son-in-law 02 Malignancy Invading Graft 180 GN With Systemic Disease (Specify) 51 Unable to Manage Self-Care 314 Stepdaughter 21 - UNCORRECTED CALCIUM 181 Goodpastures with Linear IgG and Lung Haemorrhage 05 BK Virus Nephropathy 81 Transfer Outside Australia or NZ Not corrected for albumin 315 Stepson 182 Proliferative GN with Linear IgG and No Lung Haemorrhage 82 Other Surgery Midweek, predialysis and closest to end of survey, 316 Friend 183 S.L.E. 83 Hydrothorax transplantation or death. 317 Other related (Emotionally - specify) 55 - MONOCLONAL/POLYCLONAL THERAPY 184 Henoch-Schonlein Purpura 85 Poor Nutrition 401 Non-directed, waiting list Record in order of administration, each seperate course of such drugs; a second course of the same drug should be seperately recorded. 185 Wegeners Granulomatosis 86 Scrotal Oedema 22 - PHOSPHATE 402 Non-directed, kidney exchange Complete the requested details regarding, date, identity of drug, number 186 Microscopic Polyarteritis 90 Planned Transfer After Acute PD Start Midweek, predialysis and closest to end of survey, 403 Directed kidney exchange transplantation or death. of doses given, and reason for administraton, according to the following 187 Scleroderma 91 Planned Transfer After Acute HD Start 404 Pathological codes. 190 GN Other (Specify) 99 Other (Specify) 23 - HAEMOGLOBIN 405 Other unrelated (specify) 191 Familial GN (Including Alports) Midweek, predialysis and closest to end of survey, 200 Analgesic Nephropathy 16 - CAUSE OF DEATH transplantation or death. TYPE OF AGENT NUMBER OF DOSES 300 Renal Vascular Disease (Malignant Hypertension) No prd 50 - TOTAL ISCHAEMIA (HOURS) CARDIAC From time of donor renal artery interuption or aortic Record actual number of doses 301 Renal Vascular Disease-Type Unspecified 2 Daclizumab (Zenepax) clamp, until time of release of renal artery in the given 10 Myocardial Ischaemia (Presumed) 31 - URR or Kt/V Please enter method used 4 OKT3 302 Renal Vascular Disease-Hypertension (Nephrosclerosis) recipient (clamp off). 303 Atheroembolic Disease (Cholesterol Emboli) 11 Myocardial Ischaemia And Infarction A Urea Reduction Ratio % (URR) 5 Intravenous Immunoglobulin REASON FOR USE 12 Pulmonary Oedema 6 Basilixmab 1. Prophylaxis 304 Bilateral Renal Artery Stenosis B Kt/V (By Biostat) 51 - IMMEDIATE FUNCTION 400 Polycystic Kidney Disease 13 Hyperkalaemia 7 Rituximab 7. Treatment for acute rejection C Kt/V (By UKM) 10 Immediate Function (Fall in creatinine of at least 14 Haemorrhagic Pericarditis 8. Other (specify) 401 Medullary Cystic Disease D Kt/V (By Daugirdas - Single Pool) 30% by day 2 post-transplant) 8 Polyclonal Anti T Cell 402 Infantile/Juvenile Polycystic Kidney Disease 15 Hypertensive Cardiac Failure E Kt/V (Other Method, Specify) 20 Slow Function (Failure of creatinine to fall by at 9 Other Monoclonal (Specify) 500 Reflux Nephropathy 16 Cardiac Arrest-Cause Uncertain Kt/V (for HD patients) Range 0.5-2.2 least 30% by day 2 post-transplant, but not 600 Pyelonephritis 17 Other Causes Cardiac Failure (Specify) requiring dialysis) 56 - TOTAL DAILY DRUG DOSE Enter the total daily dose for each drug where applicable; if an unlisted 700 Calculi UREA REDUCTION RATIO % 30 Delayed graft function (Requiring dialysis within VASCULAR drug is used, enter the name in the space provided marked OTHER. 701 Gout (Pre dialysis urea - post dialysis urea)x100=URR% 7 days of transplant) - Date of last post- 21 Pulmonary Embolus transplant dialysis is required 801 Diabetes Type I (Insulin Dependent) Pre dialysis urea Only those drugs taken at the listed intervals should be entered; where 22 Cerebrovascular Accident 802 Diabetes Type II (Non-Insulin Requiring) necessary provided the dose recorded on the closest day proceding the 23 Gastrointestinal Haemorrhage 803 Diabetes Type II (Insulin Requiring) 32 - ACESS IN USE requested time interval. 24 Haemorrhage From Dialysis Access Site Type at first HD - Leave blank if initial renal 000 Other (Specify) 25 Haemorrhage From Transplant Artery replacement treatment was not haemodialysis. The initial drug dose (at zero months) is the first oral maintenance 001 Uncertain Diagnosis 26 Aortic Aneurysm-Rupture Type at last HD - Enter for all patients on dose; do NOT enter the intravenous loading doses administered at or 002 Lead Nephropathy 27 Haemorrhage From Elsewhere (Specify) Haemodialysis at any time during the survey. Enter shortly after transplantation. 003 Cadmium Toxicity 28 Bowel Infarction the procedure closest to the end of the survey, 004 Renal Tuberculosis change to PD, transplantation, or death. 005 Amyloid Disease 006 Haemolytic Uraemic Syndrome 04/03/19