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Shiraz University of Medical Sciences
Pediatric Liver Transplantation
Name:
Age:
Wt. (Percentile):
Sex:
Blood group:
Pt. No.:
Age at putting on waiting list:
Liver histopathology:
Kasai Operation
Age at time of Kasai:
Complications on waiting:
Encephalopathy 
Pruritus 
GI bleeding 
Hepatorenal Sx. 
Ascites 
SBP 
Hepatopulmonary Sx. 
Infections 
Others …………
Child score:
PELD score:
Date of liver transplantation:
Age at time of Tx.
Graft type:
Graft Wt:
Donor relation:
Donor age:
Donor Wt.:
Donor blood group:
Surgery Technique:
Post Tx. Complications:
Hepatic artery thrombosis 
Portal vein thrombosis 
Hepatic vein thrombosis 
Rejection 
Infections 
BM Suppresion 
Renal problems 
Ascites 
Cardiopulmonary problems 
Biliary complications 
Convulsions 
Bowel Perforation 
Reoperation:
Cause:
Duration of admission in ICU:
Duration of admission in Ward:
Late complications:
Vascular thrombosis 
Biliary obstruction 
Infections 
Drug side effects 
PTLD 
Site:…………….
Rituximab 
Biopsy:………….
Explanted liver histopathology:
Death 
Date:
Cause:
Rejection 
Chemotherapy 