Form 1 Recipient Histocompatibility

Records
Recipient Histocompatibility Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2011
Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI ® application. Currently
in the worksheet, a red asterisk is displayed by fields that are 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:
Organ(s):

Donor Information
UNOS Donor ID#:
Donor Type:

Test Information
HLA Typing Done:

HLA Antibody Screening Done:

Crossmatch Done:

If yes, was the crossmatch prospective to
transplant:

Donor Retyped at Your Center:

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

If yes, complete Section I.

If yes, complete Section II.

If yes, complete Section III.

UNK

If yes, complete Section IV.

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

Typing Method Class I:

Serology

DNA

A

A

B

B

Bw4

Bw6

Cw

Cw

Date Typing Completed Class II:

Typing Method Class II:

Serology
DR

DR

DR51

DR52

DNA

DR53

DQ

DQ

DPB

DPB

Section II - HLA Antibody Screening
A. Most Recent
Serum Date - Most Recent Class I:

ST=

Cells
Purified HLA antigens, pooled
Target- Most Recent Class I:
Purified HLA antigens from individual phenotypes
Purified single HLA antigens

Cytotoxity testing - extended incubation
Cytotoxity testing - wash
Cytotoxity testing - wash and extended incubation
Cytotoxity testing - AHG
Technique - Most Recent Class I:
Flow cytometry with cell targets
Flow cytometry with bead targets
ELISA
Other, specify

Specify:

IgG
Technique Measures - Most Recent Class I:

IgM
Both IgG and IgM

PRA (%) - Most Recent Class I:

ST=

Class I antibody present
Anti-HLA Interpretation - Most Recent Class I:

No Class I antibody present
Unknown

Was serum screened for anti-HLA Class II
antibody:

YES

NO

Serum Date - Most Recent Class II:

ST=

Cells
Purified HLA antigens, pooled
Target - Most Recent Class II:
Purified HLA antigens from individual phenotypes
Purified single HLA antigens

Cytotoxity testing - extended incubation
Technique - Most Recent Class II:

Cytotoxity testing - wash
Cytotoxity testing - wash and extended incubation

Cytotoxity testing - AHG
Flow cytometry with cell targets
Flow cytometry with bead targets
ELISA
Other, specify

Specify:

IgG
Technique Measures - Most Recent Class II:

IgM
Both IgG and IgM

PRA (%) - Most Recent Class II:

ST=

Class II antibody present
Anti-HLA Interpretation - Most Recent Class II:

No Class II antibody present
Unknown

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

YES

Serum Date - Peak Serum Class I:

NO

ST=

Cells
Target - Peak Serum Class I:

Purified HLA antigens, pooled
Purified HLA antigens from individual phenotypes

Purified single HLA antigens

Cytotoxity testing - extended incubation
Cytotoxity testing - wash
Cytotoxity testing - wash and extended incubation
Cytotoxity testing - AHG
Technique - Peak Serum Class I:
Flow cytometry with cell targets
Flow cytometry with bead targets
ELISA
Other, specify

Specify:

IgG
Measures - Peak Serum Class I:

IgM
Both IgG and IgM

PRA (%) - Peak Serum Class I:

ST=

Class I antibody present
Anti-HLA Interpretation - Peak Serum Class I:

No Class I antibody present
Unknown

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

Serum Date - Peak Serum Class II:

YES

NO

ST=

Cells
Purified HLA antigens, pooled
Target - Peak Serum Class II:
Purified HLA antigens from individual phenotypes
Purified single HLA antigens

Cytotoxity testing - extended incubation
Cytotoxity testing - wash
Cytotoxity testing - wash and extended incubation
Cytotoxity testing - AHG
Technique - Peak Serum Class II:
Flow cytometry with cell targets
Flow cytometry with bead targets
ELISA
Other, specify

Specify:

IgG
Measures - Peak Serum Class II:

IgM
Both IgG and IgM

PRA (%) - Peak Serum Class II:

ST=

Class II antibody present
Anti-HLA Interpretation - Peak Serum Class II:
No Class II antibody present

Unknown

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

Target:

Technique:

Specify:

Measure
s:

Result:

AutoXM Result
Using This
Target and
Technique:

TCELLS
BCELLS

Unsepara
ted
lymphocyt
es

Purified
Class I
antigen

Periphera
l Blood
NIH/Extende
d
Lymph
Nodes

IgG
Wash/Exten
ded

Spleen
Purified
Class II
antigen

Positive
Indetermin
ate
Negative
IgM

Negative

AntiGlobulin
Thymocyt
es

Purified
Class I
and II
antigen

Cell
lines/clon
al cells

Platelets

Solid
Matrix

FLow
ELISA

Indetermin
ate
Bot
h
IgG
and
IgM

Positive
Not
tested
Weak
Positive
Unknown

Other,
specify

Monocyte
s

Endotheli
al cells

TCELLS

Periphera

NIH/Extende

IgG

Indetermin

Positive

l Blood

d

ate

BCELLS

Unsepara
ted
lymphocyt
es

Purified
Class I
antigen

Purified
Class II
antigen

IgM
Lymph
Nodes

Wash/Exten
ded

Spleen

AntiGlobulin

Thymocyt
es

Negative
Negative

Bot
h
IgG
and
IgM

Positive

Weak
Positive

FLow

Not
tested

Unknown

ELISA
Cell
lines/clon
al cells

Indetermin
ate

Other,
specify

Solid
Matrix
Purified
Class I
and II
antigen

Platelets

Monocyte
s

Endotheli
al cells

TCELLS
BCELLS

Unsepara
ted
lymphocyt
es

Purified
Class I
antigen

Purified
Class II

Periphera
l Blood

Lymph
Nodes

NIH/Extende
d

Positive
IgG

Wash/Exten
ded

Negative
IgM

Spleen

Thymocyt
es
Cell
lines/clon
al cells

Indetermin
ate

Negative

AntiGlobulin
FLow
ELISA
Other,
specify

Indetermin
ate
Bot
h
IgG
and
IgM

Positive
Not
tested
Weak
Positive
Unknown

antigen

Solid
Matrix

Purified
Class I
and II
antigen

Platelets

Monocyte
s

Endotheli
al cells

TCELLS
BCELLS

Unsepara
ted
lymphocyt
es

Purified
Class I
antigen

Periphera
l Blood
NIH/Extende
d
Lymph
Nodes

IgG
Wash/Exten
ded

Spleen
Purified
Class II
antigen

Thymocyt
es
Cell
lines/clon
al cells

Platelets

Solid
Matrix

Endotheli
al cells

Indetermin
ate
Negative

IgM

Negative

AntiGlobulin

Purified
Class I
and II
antigen

Monocyte
s

Positive

FLow
ELISA
Other,
specify

Indetermin
ate
Bot
h
IgG
and
IgM

Positive
Not
tested
Weak
Positive
Unknown

TCELLS
BCELLS

Unsepara
ted
lymphocyt
es

Purified
Class I
antigen

Periphera
l Blood
NIH/Extende
d

Positive

Lymph
Nodes

IgG
Wash/Exten
ded

Negative

Spleen
Purified
Class II
antigen

Indetermin
ate

IgM

Negative

AntiGlobulin
Thymocyt
es

Purified
Class I
and II
antigen

Cell
lines/clon
al cells

Platelets

Solid
Matrix

Indetermin
ate
Bot
h
IgG
and
IgM

FLow
ELISA

Positive
Not
tested
Weak
Positive
Unknown

Other,
specify

Monocyte
s

Endotheli
al 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:

TCELLS

Target:

Periphe
ral

YES

Technique:

NIH/Exten
ded

NO

Specify:

Measure
s:

Ig
G

NEG XM
by any
other
technique
with this
serum:

Yes

AutoXM
Result Using
This Target
and
Technique:

Positive

Blood
BCELLS
Lymph
Nodes
Unsepar
ated
lymphoc
ytes

Wash/Ext
ended
AntiGlobulin

Spleen
FLow

Purified
Class I
antigen

Purified
Class II
antigen

Purified
Class I
and II
antigen

Thymoc
ytes
ELISA
Cell
lines/cl
onal
cells

Ig
M

Bot
h
Ig
G
an
d
Ig
M

No

Negative

Unkn
own

Indeterm
inate
Not
tested

Unknow
n

Other,
specify

Solid
Matrix

Platelet
s

Monocyt
es

Endothe
lial cells

TCELLS

Periphe
ral
Blood

BCELLS
Lymph
Nodes
Unsepar
ated
lymphoc
ytes

Purified
Class I
antigen

Purified

Spleen

Thymoc
ytes

NIH/Exten
ded

Wash/Ext
ended

ELISA
Cell
lines/cl
onal

Ig
M

AntiGlobulin

FLow

Other,

Positive

Ig
G

Bot
h
Ig
G
an
d
Ig
M

Yes

Negative

No

Indeterm
inate

Unkn
own

Not
tested

Unknow
n

Class II
antigen

Purified
Class I
and II
antigen

cells

specify

Solid
Matrix

Platelet
s

Monocyt
es

Endothe
lial cells

TCELLS
BCELLS

Unsepar
ated
lymphoc
ytes

Purified
Class I
antigen

Purified
Class II
antigen

Purified
Class I
and II
antigen

Platelet
s

Monocyt
es

Periphe
ral
Blood

Lymph
Nodes

Spleen

Thymoc
ytes

Cell
lines/cl
onal
cells

NIH/Exten
ded

Wash/Ext
ended
AntiGlobulin

FLow

ELISA

Other,
specify
Solid
Matrix

Positive

Ig
G

Ig
M

Bot
h
Ig
G
an
d
Ig
M

Yes

Negative

No

Indeterm
inate

Unkn
own

Not
tested

Unknow
n

Endothe
lial cells

TCELLS
BCELLS

Unsepar
ated
lymphoc
ytes

Purified
Class I
antigen

Periphe
ral
Blood

Lymph
Nodes

Spleen
Purified
Class II
antigen

Purified
Class I
and II
antigen

Platelet
s

Thymoc
ytes

Cell
lines/cl
onal
cells

NIH/Exten
ded
Positive

Ig
G
Wash/Ext
ended
AntiGlobulin

FLow

ELISA

Ig
M

Bot
h
Ig
G
an
d
Ig
M

Yes

Negative

No

Indeterm
inate

Unkn
own

Not
tested

Unknow
n

Other,
specify
Solid
Matrix

Monocyt
es

Endothe
lial cells

TCELLS
BCELLS

Unsepar
ated
lymphoc
ytes

Periphe
ral
Blood

NIH/Exten
ded

Ig
G

Positive
Yes
Negative

Lymph
Nodes

Spleen

Wash/Ext
ended
AntiGlobulin

Ig
M

Bot
h
Ig

No

Unkn
own

Indeterm
inate
Not

Purified
Class I
antigen

Thymoc
ytes

G
an
d
Ig
M

FLow

tested

Unknow
n

ELISA
Purified
Class II
antigen

Purified
Class I
and II
antigen

Cell
lines/cl
onal
cells

Other,
specify

Solid
Matrix

Plateles

Monocyt
es

Endothe
lial cells

D. Autocrossmatch results:

Yes
No
Has autocrossmatch ever been positive:
Unknown
Not Tested

AutoXM Date - Positive AutoXM:

Section IV - Donor Retyping
Donor Retyped Class I:

YES

NO

UNK

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:

Peripheral Blood
Lymph Nodes
Spleen
Target Cell Source Class I:
Thymocytes
Cell lines/clonal cells
Solid Matrix

Typing Method Class I:

Serology

DNA

A

A

B

B

Bw4

Bw6

Cw

Cw

Donor Retyped Class II:

YES

NO

UNK

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

DR:

DR51:

DQ:

DPB:

DR:

DR52:

DQ:

DPB:

DR53:

Date Typing Completed Class II:

Peripheral Blood
Lymph Nodes
Spleen
Target Cell Source Class II:
Thymocytes
Cell lines/clonal cells
Solid Matrix

Typing Method Class II:

Serology
DR

DR

DR51

DR52

DR53

DQ

DQ

DPB

DPB

DNA

UNOS View Only
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