Renal Replacement Therapy 1

Illustrates Domains

Illustrates Variables

PRTRT
PRPRESP
PROCCUR
RSDISC (NSV)

Content

No modification made.

This example shows

a data collection form for renal replacement therapy, that is, for kidney transplant and chronic dialysis.

This CRF is only an example and is not meant to imply that any particular layout is preferable over another.

CRF annotated to show mapping. SDTM variables are in RED. If CDASH variable differs from SDTM, the CDASH variable is in GREY.

* Indicates variable is not approved in either CDASH or SDTM and will be submitted to the Governance Group for consideration.

Renal Replacement Therapy

Kidney Transplant PRTRT

Has the subject received a kidney transplant? PROCCUR	☐ Yes ☐ No
If yes, provide kidney transplant date (DD-MMM-YYYY) PRSTDTC PRSTDAT	_ _ / _ _ _ / _ _ _ _ (DD/MMM/YYYY)

Dialysis PRTRT

Has the subject received dialysis? PROCCUR	☐ Yes ☐ No
If yes, provide the following information:
Start Date (DD-MMM-YYYY) PRSTDTC PRSTDAT	_ _ / _ _ _ / _ _ _ _ (DD/MMM/YYYY)
Ongoing (if No, complete end date and reason discontinued) PRENRTPT="ONGOING" PRONGO	☐ Yes ☐ No
End Date (DD-MMM-YYYY) PRENDTC PRENDAT	_ _ / _ _ _ / _ _ _ _ (DD/MMM/YYYY)
Reason Discontinued Dialysis RSDISC RSDISC*	☐ No longer medically necessary ☐ Subject refused dialysis ☐ Dialysis is futile ☐ Received renal transplant ☐ Other

CDASH Metadata for this CRF can be found at: http://wiki.cdisc.org/x/ldrdAQ