Date of ESRD diagnosis __________
Enter the date of End Stage Renal Disease diagnosis in the MM/DDD/YYYY format.
Indicate the cause(s) attributed to the patient’s ESRD
Indicate all causes that have attributed to the participant’s end stage renal disease.
Diabetes
A group of diseases that result in too much sugar in the blood (high blood glucose).
Chronic glomerulonephritis
A group of kidney disease characterized by long-term inflammation and scarring of the glomeruli (microscopic structures in the kidney that filter blood and produce urine).
IgA nephropathy
A disease, also known as Berger’s disease), that causes damage to the tiny filters inside the kidneys. IgA is a protein that helps fight infections. Individual’s with IgA nephropathy, these proteins build up and form clumps inside the kidney’s tiny filters (glomeruli). The clumps of protein damage the glomeruli and can cause chronic kidney disease and can lead to kidney failure.
Polycystic kidney disease
An inherited disorder in which clusters of cysts develop primarily within the kidneys, causing kidneys to enlarge and lose function over time.
Nephrosclerosis (hypertensive)
A condition where hardening of the walls of the small arteries and arterioles of the kidney is caused by hypertension (high blood pressure). Nephrosclerosis can be classified as either benign (a gradual and prolonged deterioration of the renal arteries) or malignant (deterioration of the renal arteries occurr at a much faster rate).
Systemic lupus erythematosus (SLE)
An autoimmune disease where the immune system of the body mistakenly attacks healthy tissue. SLE that affects the kidneys is called lupus nephritis. This causes inflammation (swelling or scarring) of the small blood vessels that filter wastes in the kidney (glomeruli).
Interstitial nephritis
A disorder that effects the spaces between the tubules (small tubes) inside the kidney causing them to inflame. This reduces the kidneys’ ability to filter waste and extra fluid from the body.
Focal segmental glomerulosclerosis (FSGS)
A disease in which scar tissue develops on the parts of the kidneys that filter waste from the blood (glomeruli). Types of FSGS include:
Primary FSGS: Many people diagnosed with FSGS have no known cause. This is also called idiopathic FSGS.
Secondary FSGS: Several factors, such as infection, drug toxicity, disease such as diabetes or sickle cell disease, obesity, and other kidney disease can cause this type of FSGS.
Genetic (familial) FSGS: This form of FSGS is caused by genetic mutations. It is suspected when several members of a family shows signs of FSGS. Familial FSGS can also occur when neither parent has the disease, but each carries one copy of an abnormal gene that can be passed on to the next generation.
Unknown
Indicate unknown if the cause of ESRD is unknown.
Other, specify other
Indicate and specify if the cause of ESRD does not fall into one of the above categories.
Indicate diabetes type (Will only be required if diabetes is chosen above)
Will only be required if diabetes is chosen in the previous question. Indicate the if the participant has Type 1 or Type 2 diabetes.
Type 1
A chronic condition in which the pancreas produces little or no insulin.
Type 2
A chronic condition that affects the way the body processes blood sugar (glucose).
Specify other cause _______
If the race is indicated as “Other”, specify the race in the text box.
Was a biopsy performed to establish the cause of ESRD?
Indicate if a biopsy was performed to establish the cause of ESRD.
- Yes
- No
If yes, biopsy date _______
If a biopsy was performed. Enter the date of tissue collection in the MM/DDD/YYYY format.
Has dialysis been initiated?
Indicate if dialysis has been initiated.
- Yes
- No
If yes, enter the date of dialysis was initiated _______
If dialysis has been initiated, enter the date when dialysis was initiated in the MM/DDD/YYYY format.
Type of dialysis in use at the time of transplantation
Indicate the type of dialysis in use at the time of transplantation.
Hemodialysis
A type of treatment to filter wastes and water from the blood. Blood is pumped out of the body to an artificial kidney machine, and returned to the body by tubes that connect to the machine.
Peritoneal dialysis
A type of treatment to filter wastes and water from the blood. The lining of the belly acts as a natural filter. Waste is taken out by means of cleansing fluid called dialysate, which is washed in and out of the belly in cycles.
CCG v.1 | CRF v.1
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