Kidney Transplant Policies and Forms
Kidney Transplant Policies
Administrative
- CMS OPTN Notification
- Transplant Program Coverage Plan
- Patient Rights and Patient Notification
- Informed Consent Policy
- Transplant Program Multidisciplinary Care
- Transplant Physician Directors
- Transplant Related Occurrence Management Policy
- Patient Safety Contact
- Data Submission Policy
- Transplant Coordinator "On-Call" Policy
- Cancellation of Procedures
- RN's Caring for the Transplant Recipient and Living Donor
- Liver & Kidney Joint Written Policy between MDMC Transplant Program and MDMC Transplant Immunology Laboratory
- Communication with Dialysis Centers
- OPTN Cybersecurity Incident Reporting
- ESRD Services
Evaluation
- Multidisciplinary Team - Kidney and Pancreas
- Medical Evaluation Policy for Potential Kidney/KP Transplant Recipients
- Kidney & Pancreas Candidate Selection Criteria
- Panel Reactive Antibody (PRA) Screening/Testing Schedule- Kidney, Kidney Pancreas & SLK
- GFR Waiting Time Modification & Patient Notification Policy
- Unable to Contact/No Show/Cancellation Policy
Waitlist
- Candidate Blood Type Determination Prior to Listing
- Listing Protocol
- Transplant Candidate Waitlist Management
- Waiting Time Transfers
Transplant
- Pre- Transplant Verification and Organ Check-In
- Vessel Storage
- Transplanting Organs from COVID+ Donors
Post Transplant
- Kidney & Pancreas Immunosuppression Protocol
- Kidney & Pancreas Rejection Treatment Protocol
- Kidney & Pancreas Antimicrobial Prophylaxis Protocol
- Kidney & Pancreas CMV Prophylaxis Protocol
- BK Virus Screening Protocol
- Hepatitis B Core Positive Donor Protocol
- Management of HIV Positive Recipients
- RPR Positive Donor Protocol
- Pre & Post-Transplant Infectious Disease Testing (formerly "PHS IR" follow up)
Living Donor Policies
Administrative
- CMS OPTN Notification
- Transplant Program Coverage Plan
- Patient Rights and Patient Notification
- Informed Consent Policy
- Transplant Program Multidisciplinary Care
- Transplant Physician Directors
- Transplant Related Occurrence Management Policy
- Patient Safety Contact
- Data Submission Policy
- Transplant Coordinator "On-Call" Policy
- RN's Caring for the Transplant Recipient and Living Donor
- OPTN Cybersecurity Incident Reporting
- Liver & Kidney Joint Written Policy between MDMC Transplant Program and MDMC Transplant Immunology Laboratory
- ESRD Services
- Communication with Dialysis Centers
- Cancellation of Procedures
Pre Donation
- Living Donor Multidisciplinary Team
- Independent Living Donor Advocate
- Living Donor Candidate Selection Criteria
- Medical Evaluation for Living Donor Kidneys Recovered at MDMC
- Medical Evaluation Policy for Living Donor Kidneys Recovered at a Non MDMC Facility
- Transplanting A2 and A2B kidneys to blood group B and O candidates
- Living Donor Psychosocial Evaluation
- Paired/Non Directed Donor Protocol
- Non Domino Therapeutic Donor Clinical Evaluation
- Non- Domino Therapeutic Donor Psychosocial Evaluation
Donation Surgery
Post Donation
Kidney Forms/Consents
- Current SRTR Form Eng/Spanish front & back
- Race/Ethnicity Form (Eng & Spanish front and back)
- Kidney/Panc Radiology Review Form
- Kidney Transplant Criteria
- Kidney Workflow - Flow Chart
- Kidney Initial Evaluation Interview
- Recipient Health History
- Authorization to Disclose Health Information
- HLA Requisition Form
- KDPI Informed Consent Form
- KDPI Informed Consent Form - Spanish
- Informed Consent for Kidney Transplant
- Accepting a Hep B Core Ab Organ Consent Form
- Accepting a Hep B Core Ab Organ Consent Form - Spanish
- Accepting an HCV Organ Consent Form
- Accepting an HCV Organ Consent Form- Spanish
- A2B Consent
- Kidney Recipient Pre Transplant Class (Eng) - Jan 2025
- Kidney Recipient Pre Transplant Class (Spanish) - Jan 2025
- Kidney Education Signature Page
- My Chart Patient Portal Instructions
- Blood Type Verification at Listing
- On Call Flowsheet
- Recipient On-Call Checklist
- Match Run Verification
- Match Patient Preference for Communications
- Donor with Risk Criteria Consent Form (formerly "PHS Increased Risk" Consent)
- Blood Type Verification at Transplant
- No Crossmatch Attestation
- Post Transplant Teaching Sheet
- Kidney Teaching Checklist
- Post Transplant Daily Record (vital signs form)
- Recipient Information Request Form - STA
- Post Transplant Desensitization Treatment Authorization Form
- Transplant Activity Report
- TIEDI Completion Guideline
Living Donor/KPD Forms
- Living Donor Intake Screening
- Paired/ Non-Directed Donor Application
- Informed Consent to Donate a Kidney for Transplantation
- Living Donor Class Slides - Jan 2025
- Paired/Non Directed Consent to Donate a Kidney for Transplantation
- Spanish - Paired/Non Directed Consent to Donate a Kidney for Transplantation
- Donor Transplant Education Record
- Living Donor Follow Up Form
- KPD Patient Brochure
- KPD Donor Education Form - UNOS
- KPD Recipient Education Form - UNOS