THIS SECTION FOR ALL PATIENTS DIALYSED AT ANY TIME DURING THIS SURVEY See instructions on the back of the form AUS. & N.Z. DIALYSIS 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 UREA 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 CLEARANCE 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 urine. 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.