Test Results BK Virus

*Timeline requirements for this form are as follows:
Assessment timeframe: Week 4, Week 8, Week 12, Month 4, Month 5, Month 6, Month 7, Month 9, Month 12.
Submission timeframe:

Date blood drawn __________
Enter the date of blood draw. Enter the date in the DD/MMM/YYYY format.

Was virus detected
Indicate if virus was detected.

• Detected
• Not detected
  

If detected, indicate result _______ IU/mL

Indicate if there was evidence of the following
Select one of the following if present. If neither was present, leave blank.

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.

BK-associated nephropathy
Disease of the kidneys that is associated with BK virus which causes damage to the small blood vessels or the units in the kidneys that clean blood.

!NOTE: If the question below is answered ‘Yes’, Please report dose specifics on Concomitant Medication, MMF Dose, and Tacrolimus dose forms.

Were dose adjustments made to immunosuppression drugs
Indicate if a dose adjustment was made to any immunosuppression.

• Yes
• No
  

CCG v.1 | CRF v.1

Copyright © 2004-2024 The Medical College of Wisconsin, Inc. and NMDP. All Rights Reserved.
CIBMTR® (Center for International Blood and Marrow Transplant Research) is a research collaboration between the Medical College of Wisconsin and NMDP.