Donor Pre Transplant Work Up

King Abdul Aziz Medical City – Jeddah Kidney Transplant Program

‫المملكة العربية السعودية‬ ‫رئاسة الحرس الوطني‬ ‫ جده‬- ‫مدينة الملك عبدالعزيز الطبية‬

Pre-Transplantation Work Up Form Living Kidney Donor Referring Physician:

MRP Nephrologist:

Hospital Number:

Relationship to recipients:

Name:

Nationality:

Address:

Telephone: Sex (M/F)

Age

Weight (kg)

Height (cm)

BMI

Donor Recipient

BLOOD GROUPS

BMI = Wt/Ht² Wt = Weight (kg) Ht = Height (m)

AND TISSUE TYPING :

ABO type

A

B

Tissue typing C DR

DP

DQ

Donor Recipient A-B-DR mismatches:

HISTORY: HTN:

Yes,  No

Cancer: Yes, No  Ulcer:

Yes,  No

DM:

Yes, No

Smoker:

Yes, No

TB:

Yes, No

Kid. Stones: Yes, No

CVD: Yes, No (CVD = CerebroVascular Dis = IHD/CVA/PVD)

REVIEW OF SYSTEMS:____________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ PHYSICAL EXAMINATION: Date Blood Pressure Pulse

Temperature: ______ /

/

/

FAMILY HISTORY: ______________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ MEDICATIONS: _________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

Revised November 20, 2009

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King Abdul Aziz Medical City – Jeddah Kidney Transplant Program

‫المملكة العربية السعودية‬ ‫رئاسة الحرس الوطني‬ ‫ جده‬- ‫مدينة الملك عبدالعزيز الطبية‬

Pre-Transplantation Work Up Form Living Kidney Donor LABORATORY WORK UP: Dates (if repeat requested) Urea & BUN Electrolytes Creatinine Na K Cl Co2 Glucose Random Fasting LFT Total bilirubin Direct bilirubin Alkaline Phosphatase ALT AST Total protein Albumin Ca phosphorus Other Chemistry CK LDH Uric acid Magnesium Complete Blood Hemoglobin Counts (CBC) Hematocrit WBC Platelets Differential (N or A) Stool Analysis Occult blood Ova & Parasites Coagulation PT Profile PTT

______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______

______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______

______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______

N = normal, A - Abnormal

DONOR ID SCREENING: Revised November 20, 2009

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‫المملكة العربية السعودية‬ ‫رئاسة الحرس الوطني‬ ‫ جده‬- ‫مدينة الملك عبدالعزيز الطبية‬

King Abdul Aziz Medical City – Jeddah Kidney Transplant Program Pre-Transplantation Work Up Form Living Kidney Donor Dates (if repeat requested) Hep Bs Ag

______

______

______

Hep Bs Antibody

______

______

______

Hep Be Antibody Anti HCV Antibody CMV IgG

______ ______ ______

______ ______ ______

______ ______ ______

CMV IgM EBV IgG

______ ______

______ ______

______ ______

EBV IgM HIV 1

______ ______

______ ______

______ ______

HIV2 Brucella Abortus

______ ______

______ ______

______ ______

Brucella Melitensis Syphilis screening (VDRL) Malaria screening PPD skin test

______ ______ ______ ______

______ ______ ______ ______

______ ______ ______ ______

Sickle Cell Test

______

______

______

URINALYSIS: Date

PH

24 HOURS

Leuk

Pro

Glu

Ket

Bld

Bil

WBC

RBC

Epith

Bilhaz

Other

C&S

URINE COLLECTION :

Volum

Date

e

Protein

Creatinine

Ccr

Comments

Ccr : Creatinine Clearance

RADIOLOGICAL CXR

WORK UP :

Date Comments _________ __________________________________________

Renal Ultrasound

_________ __________________________________________

IVP

_________ __________________________________________

Renal Angiogram

_________ __________________________________________

Revised November 20, 2009

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King Abdul Aziz Medical City – Jeddah Kidney Transplant Program

‫المملكة العربية السعودية‬ ‫رئاسة الحرس الوطني‬ ‫ جده‬- ‫مدينة الملك عبدالعزيز الطبية‬

Pre-Transplantation Work Up Form Living Kidney Donor Nuclear GFR (if requested)

_________ __________________________________________

DMSA split GFR (if requested)

_________

OTHER TESTS: EKG

Date Comments _________ __________________________________________

Pap smear (Female>18, married)

_________ __________________________________________

Pregnancy Test (if indicated)

_________ __________________________________________

Stress Test (if indicated)

_________ __________________________________________

_______________

Right: _______ Left: _______

PSYCHIATRIC CONSULT: _________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ASSESSMENT AND PLAN: _________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Renal Transplant Coordinator

Head, Nephrplogy Section

____________________________ Signature

_________________________ Signature

Date: _____________

Date: _____________

Transplant Surgeon

Head, Renal Transplant Program

____________________________ Signature

_________________________ Signature

Date: _____________

Date: _____________

Revised November 20, 2009

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