Living Liver Donor Registry
Name of the Donor
Transplant Unit Incharge
Height (m)
Admission Registration No in Hospital
Weight (Kg)
Date of Birth
Gender
BMI
Relationship with Recipient
Brother
Sister
Mother
Father
Son
Daughter
Spouse
Grandfather
GrandMother
GrandSon
GrandDaughter
Anyother (specify ------)
Whether Donor is relative of Recipient as per Transplantation of Human Organs Act (THOA):
Yes
No
If unrelated, whether approved by authorization committee:
Psychiatric assessment was done?
Yes
No
Y/N
Donor Co-Morbidities:
Diabetes
None
IDDM
NIDDM
Hypertension:
Yes
No
If yes please specify Name of Drug:
--------------------Dialysis
No Dialysis
Haemo Dialysis
Peritoneal Dialysis
Coronary Artery Disease: Yes
Other Viruses
Serological Details
No
CMV
pos
neg
EBV
pos
neg
neg
HSV
pos
neg
pos
neg
VZV
pos
neg
Anti-Hbc
pos
neg
HIV
pos
neg
HBV DNA
pos
neg
Hep D Delta Ab
pos
neg
Anti-HCV
pos
neg
HCV PCR
pos
neg
HbsAg
pos
HBsAb
level____
Baseline Tests:
Procoagulant Screen: Yes
No
Total Bilirubin
………………….. µmol/L
INR
…………………….
SGPT
………………….. U/L
Prothrombin Time
…………………….. S
SGOT
………………….. U/L
Fibrinogen
…………………….. g/L
GGT
………………….. U/L
ALP
………………….. U/L
Blood Group:
TP
………………….. g/l
A
Alb
………………….. g/l
Creatinine
………………….. µmol/L
A2
O
B
AB
A2B
Imaging Details
Name of Investigation:
Modality:
Graft / Recipient Wt Ratio:
(Estimated Volume - Donor Graft):
Residual Liver:
Anatomical Details
Size
Hepatic Artery
Comment: ………………………………..
Portal Vein
Comment: ……………………………….
Hepatic Vein
Comment: ……………………………….
Biliary
Comment: ……………………………….
Liver Biopsy Report
Normal
Abnormal
If Abnormal then, Specify
Micro Vesicular fat:
……………………………………………………….
%
Macro Vesicular fat:
%
Peri Operative Data
Donor Operation
Date of Operation:
Finding at variance with preop assessment? …………………………………………………………………………..
Segment removed*:
Comment: _________________________________
Duration of surgery:
MHV Included with graft:
Yes
No
Reconstruction of MHV [Specify] ___________________________________________
Total blood products
Administered (*during / after surgery)
Peak Postoperative:
RBC
ICU Stay
Total bilirubin:
AST
FFP
Hospital Stay
Cretinine
ALT
Platelets
INR
Peri Operative Data
Complications
Cardiac
Respiratory
Gastrointestinal
Thromboembolic
None
None
None
None
Arrhythmia
Atelectasis
lleus
Deep vein thrombosis
Myocardial infarct
Pneumonia
Bowel obstruction
Pulmonary embolus
Cardiac failure
Pleural effusion
Pancreatitis
Other [Specify]
Other [Specify]
Empyema
Other [Specify]
…………………………………
…………………………..
Other [Specify]
………………………………….
……………………………..
Surgical
Miscellaneous
None
Bleeding [specify] ____________________
UTI
Bile duct injury [Specify]__________
vascular thrombosis [Specify] __________
Line sepsis
Bile stained drainage
Vascular Injury [Specify] ______________
Resolved spontaneously: Yes
No
If Yes Date:_____
Intervention [Specify]__________________
Wound Infection [Specify] _____________
Other [Specify] ______________________
Anaesthetic [specify]
………………………………………
……………………………………..
Psychiatric [specify]
………………………………………..
………………………………………..
Date:______________
Site (if Known):__________________
Other [specify]
……………………………………….
……………………………………….
Reoperation: Yes No
Note :- If yes then fill below details
Date
1. Specify _____________________
……../………/…….
2. Specify _____________________
……../……../……..
3. Specify _____________________
……../……../……..
Non-Operative intervention: Yes
No
Note :- If yes then fill below details
Date
1. Specify ______________________
……../………/……..
2. Specify ______________________
……../………/……..
3. Specify ______________________
……../………/……..