Transplant Pathology Internet Services
Transplant Pathology Internet Services

Liver Allograft Chronic Rejection Study Case Submission Form
Please complete all fields below and when you have finished, select the 'Submit Information' button at the bottom of the screen to submit the case form. You can search your data by entering organization code and select the "Search" button at the bottom of the screen to start the seaerch.

Organization:
 PID:
 CID:
 Age:
 Sex:
Date of Biopsy (DD-MMM-YY):
 Date of Transplant (DD-MMM-YY):
Case Entry Criteria:
Original Disease [1]:
Original Disease [2]:
Original Disease [3]:
Baseline Immunosuppression Regimen:
 Specimen Type:
TBil (mg/dL):
 ALT (IU/L):
 AST (IU/L):
 ALP (IU/L):
 GGTP (IU/L):
Portal Tracts
Inflammatory Severity:
 Bile Duct Infl./Damage:
 Portal Vein Endotheliitis:
Total # Portal Tracts (count 50 if failed allograft):
 # Portal Tracts without Bile Ducts:
# Portal Tracts without Arterial Branches:
Dysplastic Ducts:
 Interface Activity:
 Fibrosis:
Arterial
Intimal Inflammation:
 Foam cells:
 Fibrosis:
Lobule / Parenchyma
Disarray:
 Overall Inflammation:
 Spotty Necrosis:
Perivenular
Inflammation:
 Necrosis:
 Ballooning: Congestion / Hemorrhage: Centeral Vein Endotheliitis:
Foam Cell Clusters:
Cholestasis
Severity:
 Location:
CMV Infection
Microabscesses: In Situ Hybridization: PCR: Inclusion Bodies:
Hilum (Failed Allografts/Autopsies Only)
Liver Weight (gm):
 Arteriopathy:
 Large bile duct inflammation:
Arterial intima
Foam Cells: Myofibroblast: Inflammation:
Media
Foam Cells: Inflammation:
Adventitia
Foam Cells: Fibrosis: Inflammation:
Allograft Diagnosis
Allograft Diagnosis [1]:
Allograft Diagnosis [2]:
Allograft Diagnosis [3]:
Case Comments:
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