Form 6 Recipient Histocompatibility

Records
Recipient Histocompatibility Worksheet
The revised worksheet sample is for reference purposes only and is pending OMB approval.
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI

B.

application. Currently in the worksheet, a red asterisk is displayed by fields that are

B.

required, independent of what other data may be provided. Based on data provided through the online TIEDI application, additional fields that are dependent on responses provided in these
required fields may become required as well. However, since those fields are not required in every case, they are not marked with a red asterisk.

Provider Information
Lab:
TX Center:

Recipient Information
Name:

DOB:

Transplant Date:
SSN:

Gender:

HIC:

Transplant Date:

Organ(s):

Donor Information
UNOS Donor ID#:
Donor Type:

Test Information
HLA typing done:

j NO
k
l
m
j YES n
k
l
m
n

If yes, complete Section I.

HLA antibody screening done:

j NO
k
l
m
j YES n
k
l
m
n

If yes, complete Section II.

Crossmatch done:

j NO
k
l
m
j YES n
k
l
m
n

If yes, complete Section III.

If yes, was the crossmatch prospective to transplant:

Donor retyped at your center:

Section I - Recipient HLA Typing
Date Typing Completed Class I:

Typing Method Class I:

c Serology g
d
e
f
g
c DNA
d
e
f
A

A

B

B

Bw4

Bw6

Cw

Cw

j NO n
k
l
m
j YES n
k
l
m
n
j UNK
k
l
m
j YES n
k
l
m
n
j NO
k
l
m

If yes, complete Section IV.

Date Typing Completed Class II:

Typing Method Class II:

c Serology g
d
e
f
g
c DNA
d
e
f
DR

DR

DR51

DR52

DR53

DQ

DQ

DPw

DPw

Section II - HLA antibody screening
A. Most Recent
Serum Date - Most Recent Class I:

ST=

j Cells
k
l
m
n
Target- Most Recent Class I:

j Purified HLA antigens, pooled
k
l
m
n
j Purified HLA antigens from individual phenotypes
k
l
m
n
j Purified single HLA antigens
k
l
m
n

j Cytotoxity testing - extended incubation
k
l
m
n
j Cytotoxity testing - wash
k
l
m
n
j Cytotoxity testing - wash and extended incubation
k
l
m
n
Technique - Most Recent Class I:

j Cytotoxity testing - AHG
k
l
m
n
j Flow cytometry with cell targets
k
l
m
n
j Flow cytometry with bead targets
k
l
m
n
j ELISA
k
l
m
n
j Other, specify
k
l
m
n

Specify:

Technique Measures - Most Recent Class I:

j IgG
k
l
m
n
j IgM
k
l
m
n

j Both IgG and IgM
k
l
m
n

PRA (%) - Most Recent Class I:

ST=

j Class I antibody present
k
l
m
n
Anti-HLA Interpretation - Most Recent Class I:

j No Class I antibody present
k
l
m
n

j Unknown
k
l
m
n

Was serum screened for anti-HLA Class II antibody:

j YES n
k
l
m
n
j NO
k
l
m

Serum Date - Most Recent Class II:

ST=

j Cells
k
l
m
n
Target - Most Recent Class II:

j Purified HLA antigens, pooled
k
l
m
n
j Purified HLA antigens from individual phenotypes
k
l
m
n
j Purified single HLA antigens
k
l
m
n

j Cytotoxity testing - extended incubation
k
l
m
n
j Cytotoxity testing - wash
k
l
m
n
j Cytotoxity testing - wash and extended incubation
k
l
m
n
Technique - Most Recent Class II:

j Cytotoxity testing - AHG
k
l
m
n
j Flow cytometry with cell targets
k
l
m
n

j Flow cytometry with bead targets
k
l
m
n
j ELISA
k
l
m
n

j Other, specify
k
l
m
n
Specify:

j IgG
k
l
m
n
Technique Measures - Most Recent Class II:

j IgM
k
l
m
n
j Both IgG and IgM
k
l
m
n

PRA (%) - Most Recent Class II:

ST=

j Class II antibody present
k
l
m
n
Anti-HLA Interpretation - Most Recent Class II:

j No Class II antibody present
k
l
m
n
j Unknown
k
l
m
n

B. Peak

Were any sera tested pre-transplant that contain anti-HLA Class I
antibody:

j YES n
k
l
m
n
j NO
k
l
m

Serum Date - Peak Serum Class I:

ST=

j Cells
k
l
m
n
Target - Peak Serum Class I:

j Purified HLA antigens, pooled
k
l
m
n
j Purified HLA antigens from individual phenotypes
k
l
m
n
j Purified single HLA antigens
k
l
m
n

j Cytotoxity testing - extended incubation
k
l
m
n
j Cytotoxity testing - wash
k
l
m
n
j Cytotoxity testing - wash and extended incubation
k
l
m
n
Technique - Peak Serum Class I:

j Cytotoxity testing - AHG
k
l
m
n
j Flow cytometry with cell targets
k
l
m
n
j Flow cytometry with bead targets
k
l
m
n
j ELISA
k
l
m
n
j Other, specify
k
l
m
n

Specify:

j IgG
k
l
m
n
Measures - Peak Serum Class I:

j IgM
k
l
m
n
j Both IgG and IgM
k
l
m
n

PRA (%) - Peak Serum Class I:

ST=

j Class I antibody present
k
l
m
n
Anti-HLA Interpretation - Peak Serum Class I:

j No Class I antibody present
k
l
m
n

j Unknown
k
l
m
n

Were any sera tested pre-transplant that contain anti-HLA Class II
antibody:

j YES n
k
l
m
n
j NO
k
l
m

Serum Date - Peak Serum Class II:

ST=

j Cells
k
l
m
n
Target - Peak Serum Class II:

j Purified HLA antigens, pooled
k
l
m
n
j Purified HLA antigens from individual phenotypes
k
l
m
n

j Purified single HLA antigens
k
l
m
n

j Cytotoxity testing - extended incubation
k
l
m
n
j Cytotoxity testing - wash
k
l
m
n
j Cytotoxity testing - wash and extended incubation
k
l
m
n

j Cytotoxity testing - AHG
k
l
m
n

Technique - Peak Serum Class II:

j Flow cytometry with cell targets
k
l
m
n

j Flow cytometry with bead targets
k
l
m
n
j ELISA
k
l
m
n
j Other, specify
k
l
m
n
Specify:

j IgG
k
l
m
n
j IgM
k
l
m
n

Measures - Peak Serum Class II:

j Both IgG and IgM
k
l
m
n

PRA (%) - Peak Serum Class II:

ST=

j Class II antibody present
k
l
m
n
j No Class II antibody present
k
l
m
n

Anti-HLA Interpretation - Peak Serum Class II:

j Unknown
k
l
m
n

Section III - Crossmatch
A. Most Recent
Date of crossmatch serum:
Cell Type:

Target:

Technique:

Specify:

Measures:

Result:

AutoXM Result Using
This Target and
Technique:

j T-CELLS
k
l
m
n
j B-CELLS
k
l
m
n
j Unseparated
k
l
m
n
lymphocytes
j Purified Class I
k
l
m
n
antigen
j Purified Class
k
l
m
n

j Peripheral
k
l
m
n
Blood
j Lymph
k
l
m
n
Nodes

j Spleen
k
l
m
n

II antigen

j Purified Class I
k
l
m
n
and II antigen

j Platelets
k
l
m
n
j Monocytes
k
l
m
n

j Thymocytes
k
l
m
n

j
k
l
m
n
NIH/Extended

j
k
l
m
n
Wash/Extended

j Antik
l
m
n
Globulin

j FLow
k
l
m
n

j Cell
k
l
m
n
lines/clonal cells

j ELISA
k
l
m
n

j Solid Matrix
k
l
m
n

j Other,
k
l
m
n
specify

j Endothelial
k
l
m
n
cells
j T-CELLS
k
l
m
n
j B-CELLS
k
l
m
n
j Unseparated
k
l
m
n
lymphocytes

j Peripheral
k
l
m
n
Blood

j
k
l
m
n
NIH/Extended

j
k
l
m
n

j IgG
k
l
m
n

Indeterminate

j IgM
k
l
m
n

j Negative
k
l
m
n

j Both
k
l
m
n

j Positive
k
l
m
n

IgG and
IgM

j Weak
k
l
m
n
Positive

j Positive
k
l
m
n
j Negative
k
l
m
n
j Indeterminate
k
l
m
n
j Not tested
k
l
m
n
j Unknown
k
l
m
n

j Purified Class I
k
l
m
n
antigen

j Lymph
k
l
m
n
Nodes

j Purified Class
k
l
m
n

j Spleen
k
l
m
n

II antigen

j Purified Class I
k
l
m
n
and II antigen
j Platelets
k
l
m
n
j Monocytes
k
l
m
n

j Thymocytes
k
l
m
n
j Cell
k
l
m
n

j
k
l
m
n
Wash/Extended

j Antik
l
m
n
Globulin

j FLow
k
l
m
n

lines/clonal cells

j ELISA
k
l
m
n

j Solid Matrix
k
l
m
n

j Other,
k
l
m
n
specify

j IgG
k
l
m
n
j IgM
k
l
m
n
j Both
k
l
m
n
IgG and
IgM

j
k
l
m
n
Indeterminate

j Negative
k
l
m
n
j Positive
k
l
m
n
j Weak
k
l
m
n
Positive

j Positive
k
l
m
n
j Negative
k
l
m
n
j Indeterminate
k
l
m
n
j Not tested
k
l
m
n
j Unknown
k
l
m
n

j Endothelial
k
l
m
n
cells
j T-CELLS
k
l
m
n
j B-CELLS
k
l
m
n
j Unseparated
k
l
m
n
lymphocytes
j Purified Class I
k
l
m
n
antigen

j Purified Class
k
l
m
n

j Peripheral
k
l
m
n
Blood

j Lymph
k
l
m
n
Nodes
j Spleen
k
l
m
n

II antigen

j Purified Class I
k
l
m
n
and II antigen
j Platelets
k
l
m
n
j Monocytes
k
l
m
n

j Thymocytes
k
l
m
n
j Cell
k
l
m
n

j
k
l
m
n
NIH/Extended

j
k
l
m
n
Wash/Extended

j Antik
l
m
n
Globulin

j FLow
k
l
m
n

lines/clonal cells

j ELISA
k
l
m
n

j Solid Matrix
k
l
m
n

j Other,
k
l
m
n
specify

j Peripheral
k
l
m
n

NIH/Extended

j
k
l
m
n

j IgG
k
l
m
n

Indeterminate

j IgM
k
l
m
n

j Negative
k
l
m
n

j Both
k
l
m
n

j Positive
k
l
m
n

IgG and
IgM

j Weak
k
l
m
n
Positive

j Positive
k
l
m
n
j Negative
k
l
m
n
j Indeterminate
k
l
m
n
j Not tested
k
l
m
n
j Unknown
k
l
m
n

j Endothelial
k
l
m
n
cells
j T-CELLS
k
l
m
n
j B-CELLS
k
l
m
n
j Unseparated
k
l
m
n
lymphocytes

Blood

j Purified Class I
k
l
m
n
antigen

j Lymph
k
l
m
n
Nodes

j Purified Class
k
l
m
n

j Spleen
k
l
m
n

II antigen

j Purified Class I
k
l
m
n
and II antigen
j Platelets
k
l
m
n
j Monocytes
k
l
m
n

j Thymocytes
k
l
m
n
j Cell
k
l
m
n

j
k
l
m
n
j
k
l
m
n
Wash/Extended

j Antik
l
m
n
Globulin

j FLow
k
l
m
n

lines/clonal cells

j ELISA
k
l
m
n

j Solid Matrix
k
l
m
n

j Other,
k
l
m
n
specify

j
k
l
m
n

j IgG
k
l
m
n

Indeterminate

j IgM
k
l
m
n

j Negative
k
l
m
n

j Both
k
l
m
n

j Positive
k
l
m
n

IgG and
IgM

j Weak
k
l
m
n
Positive

j Positive
k
l
m
n
j Negative
k
l
m
n
j Indeterminate
k
l
m
n
j Not tested
k
l
m
n
j Unknown
k
l
m
n

j Endothelial
k
l
m
n
cells
j T-CELLS
k
l
m
n
j B-CELLS
k
l
m
n
j Unseparated
k
l
m
n
lymphocytes
j Purified Class I
k
l
m
n
antigen

j Purified Class
k
l
m
n
II antigen
j Purified Class I
k
l
m
n
and II antigen

j Peripheral
k
l
m
n
Blood
j Lymph
k
l
m
n
Nodes

j Spleen
k
l
m
n
j Thymocytes
k
l
m
n
j Cell
k
l
m
n
lines/clonal cells

j
k
l
m
n
NIH/Extended

j
k
l
m
n

Indeterminate

j IgM
k
l
m
n

j Negative
k
l
m
n

j Both
k
l
m
n

j Positive
k
l
m
n

Wash/Extended

j Antik
l
m
n
Globulin
j FLow
k
l
m
n
j ELISA
k
l
m
n

j
k
l
m
n

j IgG
k
l
m
n

IgG and
IgM

j Weak
k
l
m
n
Positive

j Positive
k
l
m
n
j Negative
k
l
m
n
j Indeterminate
k
l
m
n
j Not tested
k
l
m
n
j Unknown
k
l
m
n

j Platelets
k
l
m
n

j Other,
k
l
m
n
specify

j Solid Matrix
k
l
m
n

j Monocytes
k
l
m
n
j Endothelial
k
l
m
n
cells

B. Date of crossmatch serum - Least Recent (for reference
purposes):

C. Positive crossmatch with sera other than the most recent by
any method:
Serum Date:

Cell Type:

Target:

j YES n
k
l
m
n
j NO
k
l
m
Technique:

Specify:

Measures: NEG XM by
AutoXM Result
any other
Using This Target
technique with and Technique:
this serum:

j Tk
l
m
n
CELLS
j Bk
l
m
n
CELLS
j
k
l
m
n
Unseparated
lymphocytes

j Purified
k
l
m
n
Class I
antigen
j Purified
k
l
m
n
Class II
antigen

j Purified
k
l
m
n
Class I and II
antigen

j
k
l
m
n
Platelets

j
k
l
m
n
Peripheral
Blood

j Lymph
k
l
m
n
Nodes

j Spleen
k
l
m
n

j
k
l
m
n
Thymocytes

j Cell
k
l
m
n
lines/clonal
cells

j Solid
k
l
m
n
Matrix

j
k
l
m
n
NIH/Extended

j
k
l
m
n
Wash/Extended

j Antik
l
m
n
Globulin

j FLow
k
l
m
n
j ELISA
k
l
m
n

j Other,
k
l
m
n

j
k
l
m
n

j Positive
k
l
m
n

IgG

j
k
l
m
n

j Yes
k
l
m
n

IgM

j No
k
l
m
n

j
k
l
m
n
Both
IgG
and
IgM

j
k
l
m
n
Unknown

j Negative
k
l
m
n
j
k
l
m
n
Indeterminate

j Not tested
k
l
m
n
j Unknown
k
l
m
n

specify

j
k
l
m
n
Monocytes

j
k
l
m
n
Endothelial
cells

j Tk
l
m
n
CELLS
j Bk
l
m
n
CELLS
j
k
l
m
n
Unseparated
lymphocytes

j Purified
k
l
m
n
Class I
antigen
j Purified
k
l
m
n
Class II
antigen

j
k
l
m
n
Peripheral
Blood

j Lymph
k
l
m
n
Nodes

j Spleen
k
l
m
n
j
k
l
m
n
Thymocytes

j Cell
k
l
m
n

j Purified
k
l
m
n

lines/clonal
cells

Class I and II
antigen

j Solid
k
l
m
n

j
k
l
m
n
Platelets

j
k
l
m
n

Matrix

j
k
l
m
n
NIH/Extended

j
k
l
m
n
Wash/Extended

j Antik
l
m
n
Globulin
j FLow
k
l
m
n

j ELISA
k
l
m
n
j Other,
k
l
m
n
specify

j
k
l
m
n

j Positive
k
l
m
n

IgG

j
k
l
m
n

j Yes
k
l
m
n

IgM

j No
k
l
m
n

j
k
l
m
n
Both
IgG
and
IgM

j
k
l
m
n
Unknown

j Negative
k
l
m
n
j
k
l
m
n
Indeterminate

j Not tested
k
l
m
n
j Unknown
k
l
m
n

Monocytes

j
k
l
m
n
Endothelial
cells

j Tk
l
m
n
CELLS

j Bk
l
m
n
CELLS
j
k
l
m
n
Unseparated
lymphocytes

j Purified
k
l
m
n
Class I
antigen

j Purified
k
l
m
n
Class II
antigen

j Purified
k
l
m
n
Class I and II
antigen

j
k
l
m
n
Platelets

j
k
l
m
n
Peripheral
Blood

j Lymph
k
l
m
n
Nodes

j Spleen
k
l
m
n
j
k
l
m
n
Thymocytes

j Cell
k
l
m
n
lines/clonal
cells

j Solid
k
l
m
n

j
k
l
m
n
NIH/Extended

j
k
l
m
n
Wash/Extended

j Antik
l
m
n
Globulin

j FLow
k
l
m
n
j ELISA
k
l
m
n
j Other,
k
l
m
n

j
k
l
m
n

j Positive
k
l
m
n

IgG

j
k
l
m
n

j Yes
k
l
m
n

IgM

j No
k
l
m
n

j
k
l
m
n
Both
IgG
and
IgM

j
k
l
m
n
Unknown

j Negative
k
l
m
n
j
k
l
m
n
Indeterminate

j Not tested
k
l
m
n
j Unknown
k
l
m
n

specify

Matrix

j
k
l
m
n
Monocytes

j
k
l
m
n
Endothelial
cells

j Tk
l
m
n
CELLS
j Bk
l
m
n
CELLS
j
k
l
m
n
Unseparated
lymphocytes

j
k
l
m
n
Peripheral
Blood

j Purified
k
l
m
n
Class I
antigen

j Lymph
k
l
m
n
Nodes

j Purified
k
l
m
n

j Spleen
k
l
m
n

Class II
antigen

j Purified
k
l
m
n
Class I and II
antigen
j
k
l
m
n
Platelets

j
k
l
m
n
Monocytes

j
k
l
m
n
Endothelial
cells

j Tk
l
m
n
CELLS

j Bk
l
m
n
CELLS

j
k
l
m
n
Thymocytes

j Cell
k
l
m
n
lines/clonal
cells

j Solid
k
l
m
n
Matrix

j
k
l
m
n
NIH/Extended

j
k
l
m
n
Wash/Extended

j Antik
l
m
n
Globulin

j FLow
k
l
m
n
j ELISA
k
l
m
n
j Other,
k
l
m
n
specify

j
k
l
m
n

j Positive
k
l
m
n

IgG

j
k
l
m
n

j Yes
k
l
m
n

IgM

j No
k
l
m
n

j
k
l
m
n
Both
IgG
and
IgM

j
k
l
m
n
Unknown

j Negative
k
l
m
n
j
k
l
m
n
Indeterminate

j Not tested
k
l
m
n
j Unknown
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Unseparated
lymphocytes

Peripheral
Blood

j Purified
k
l
m
n
Class I
antigen

j Lymph
k
l
m
n
Nodes

j Purified
k
l
m
n
Class II
antigen

j Purified
k
l
m
n
Class I and II
antigen

j Spleen
k
l
m
n
j
k
l
m
n
Thymocytes

j Cell
k
l
m
n
lines/clonal
cells
j Solid
k
l
m
n

j
k
l
m
n
Platelets

j
k
l
m
n

j
k
l
m
n
NIH/Extended

j
k
l
m
n
Wash/Extended

j Antik
l
m
n
Globulin
j FLow
k
l
m
n
j ELISA
k
l
m
n

Matrix

j Other,
k
l
m
n

j
k
l
m
n
j
k
l
m
n

j Yes
k
l
m
n

IgM

j No
k
l
m
n

j
k
l
m
n
Both
IgG
and
IgM

specify

Monocytes

j
k
l
m
n
Endothelial
cells

D. Autocrossmatch results:

j Yes
k
l
m
n
j No
k
l
m
n

Has autocrossmatch ever been positive:

j Unknown
k
l
m
n
j Not Tested
k
l
m
n

AutoXM Date - Positive AutoXM:

Section IV - Donor Retyping

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Donor Retyped Class I:

Donor HLA values entered through Placement or on the Donor Histocompatibility Form:
A:

B:

Bw4:

Cw:

A:

B:

Bw6:

Cw:

Date Typing Completed Class I:

c Peripheral Blood
d
e
f
g
c Lymph Nodes
d
e
f
g
Target Cell Source Class I:

c Spleen
d
e
f
g
c Thymocytes
d
e
f
g
c Cell lines/clonal cells
d
e
f
g
c Solid Matrix
d
e
f
g

Typing Method Class I:

c Serology g
d
e
f
g
c DNA
d
e
f

A

j Positive
k
l
m
n

IgG

j
k
l
m
n
Unknown

j Negative
k
l
m
n
j
k
l
m
n
Indeterminate

j Not tested
k
l
m
n
j Unknown
k
l
m
n

A

B

B

Bw4

Bw6

Cw

Cw

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Donor Retyped Class II:

Donor HLA values entered through Placement or on the Donor Histocompatibility Form:
DR:
DR:

DR51:

DQ:

DPw:

DR52:

DQ:

DPw:

DR53:

Date Typing Completed Class II:

c Peripheral Blood
d
e
f
g
c Lymph Nodes
d
e
f
g
Target Cell Source Class II:

c Spleen
d
e
f
g
c Thymocytes
d
e
f
g
c Cell lines/clonal cells
d
e
f
g
c Solid Matrix
d
e
f
g

Typing Method Class II:

c Serology g
d
e
f
g
c DNA
d
e
f
DR

DR

DR51

DR52

DR53

DQ

DQ

DPw

DPw