The Thalassemia Post-Infusion (2158) Form is one of the Comprehensive Report Forms. This form captures thalassemia-specific post-infusion data such as the recipient’s thalassemia diagnosis, donor related information, transfusion, hepatic, cardiac, renal, iron overload assessment prior to the start of the preparative regimen, hematologic labs, organ impairment, and pre-infusion therapy.
This form must be completed for all transplant and gene therapy recipients, randomized to the Comprehensive Report Form (CRF) track whose primary disease is reported as Hemoglobinopathies – Transfusion dependent thalassemia: Transfusion beta dependent thalassemia or Other transfusion dependent thalassemia on the Disease Classification (2402) Form.
Q1 – 15: Post-Infusion Disease Testing
Q16 – 17: Transfusion Therapy
Q18 – 29: Treatment
Q30: Splenic Assessments
Q31 – 54: Hepatic Assessments
Q55 – 63: Cardiac Assessments
Q64 – 66: Renal Assessments
Q67 – 81: Additional Iron Overload Assessments
Q82 – 90: Additional Hematologic Labs
Q91 – 102: Specify Existing Other Organ Impairments
Q103 – 110: Disease Modifying Therapies
Sections of the Forms Instruction Manual are frequently updated. The most recent updates to the manual can be found below. For additional information, select the manual section and review the updated text.
If you need to reference the historical Manual Change History for this form, please reference the retired manual section on the Retired Forms Manuals webpage.
|4/22/2019||2158: Thalassemia Post-Infusion||Add||Version 1 of the 2158: Thalassemia Post-Infusion section of the Forms Instructions Manual released. Version 1 corresponds to revision 1 of the Form 2158.|
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