Home transplant center: Center code and center name. This field is required.
Is this a non-directed donor?: This is a required field.
Yes
No
KPD candidate ID: Unique numeric value assigned by system when candidate is entered into KPD. This field is required if non-directed donor is set to No.
Donor name: Donor’s last name, first name, and middle initial (if applicable). This field is required.
SSN: Donor’s social security number. Numeric format XXXXXXXXX. This field is required.
Date of birth: Donor’s date of birth. MM/DD/YYYY format. This field is required.
Donor status: This field is required.
Active
Inactive
Home transplant center: Transplant center code and center name. This field is required.
Is this a non-directed donor?: This field is required.
Yes
No
Donor name: Donor's last name, first name, and middle initial (if applicable). This field is required.
SSN: Donor's Social Security Number. Numeric format XXXXXXXXX. This field is required.
Date of birth: Donor's date of birth in MM/DD/YYYY format. This field is required.
Donor status: (Values: Active, Inactive). This field is required.
Active
Inactive
Last name: The KPD donor's last name. Alphanumeric. This field is required for eligibility on the match run.
First name: The KPD donor's first name. Alphanumeric. This field is required for eligibility on the match run.
Middle initial: The KPD donor’s middle initial (if applicable).
SSN: The KPD donor's social security number. Numeric format XXXXXXXXX. This field is required.
Date of birth: The KPD donor's date of birth in MM/DD/YYYY format. This field is required.
Current age: The KPD donor's current age. The KPD donor's current age is calculated based on the date of birth and today's date. This field cannot be updated on this page.
Gender: KPD donor gender. This field is required for eligibility on the match run.
Male
Female
Center's patient ID: KPD donor's patient ID.
State of permanent residence: KPD donor's state of permanent residence.
Permanent zip code: Permanent zip code in which the KPD donor lives. Numeric format - XXXXX or XXXXX-XXXX.
Ethnicity: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of ethnicity is aligned to this standard.
OMB defines ethnicity to be whether or not a person self-identifies as Hispanic or Latino. For this reason, ethnicity is broken out into two categories, (1) Hispanic or Latino or (2) Not Hispanic or Latino. Select one ethnicity category or select 'Ethnicity Not Reported' if a category was not self-identified by the person.
This field is required.
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Not Hispanic or Latino
Ethnicity Not Reported – Select if person did not self-identify an ethnicity category.
Race: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of race is aligned to this standard. OMB defines race as a person’s self-identification with one or more social groups.
An individual can select one or more race categories (1) White, (2) Black or African American, (3) Asian, (4) American Indian or Alaska Native, (5) Native Hawaiian or Other Pacific Islander, or Race Not Reported.
This field is required.
Select one or more race sub-categories or origins. Select 'Other Origin' if origin is not listed. Select 'Origin Not Reported' if the origin was not self-identified by the person.
White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
European Descent
Arab or Middle Eastern
North African (non-Black)
Other Origin
Origin Not Reported
Black or African American – A person having origins in any of the Black racial groups of Africa.
African American
African (Continental)
West Indian
Haitian
Other Origin
Origin Not Reported
American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.
American Indian
Eskimo
Aleutian
Alaska Indian
Other Origin
Origin Not Reported
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Asian Indian/Indian Sub-Continent
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Origin
Origin Not Reported
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Origin
Origin Not Reported
Race Not Reported – Select if person did not self-identify a race category or origin.
ABO: KPD Donor ABO. This field is required for eligibility on the match run. Once the ABO has been verified by a second user, this field cannot be updated.
O
A
A1
A2
B
AB
A1B
A2B
Note: If the second user only verifies the "primary" blood type, the sub-types can be updated. Once the subtypes have been entered and verified, the ABO blood type can no longer be updated.
Height: KPD donor height. Format entered in feet and inches. This field is required for eligibility on the match run. The height also displays in centimeters.
Weight: KPD donor's weight in kilograms. This field is required for eligibility on the match run. The weight also displays in pounds.
BMI: Body Mass Index is a measure that adjusts body weight for height. The BMI is calculated by the system based on the ratio of the weight of the body in kilograms to the square of its height in meters. This field cannot be updated.
Is this a non-directed donor?: This field is required.
Yes
No
Intended KPD Candidate ID: This field is required if the non-directed donor field is set to No.
Candidate name: KPD paired candidate name from candidate record. This field is read-only and only displays if the donor is a non-directed donor.
Donor's relationship to candidate: This field is required.
Biological, blood-related parent
Biological, blood-related child
Biological, blood-related identical twin
Biological, blood-related full sibling
Biological, blood-related half sibling
Biological, blood-related other relative: specify
Non Biol., spouse
Non Biol., life partner
Non Biol., socially related: specify
Non Biol., Other unrel. direct donation: specify
Are you willing to start a chain that continues with a bridge donor?: This field is required for eligibility on the match run.
Yes
No
Does the donor have health insurance?:
Yes
No
Unknown
Has the donor signed the Agreement to participate in the KPD Pilot Program?: This field is required for eligibility on the match run.
Yes
No
Has the donor signed a HIPAA form so that medical information may be shared?: This field is required for eligibility on the match run.
Yes
No
Has the donor signed a living donor consent form as outlined in the KPD Operational Guidelines?: This field is required for eligibility on the match run.
Yes
No
Has the donor undergone an evaluation as outlined in the KPD Operational Guidelines?: This field is required for eligibility on the match run.
Yes
No
Has the donor had all age appropriate cancer screenings as defined by the American Cancer Society?: This field is required for eligibility on the match run.
Yes
No
KPD status: This field is required.
Active
Inactive
Removed
Inactive reason: If KPD status is set to Inactive, the Inactive reason is required.
List of inactive reasons:
Temporarily Ineligibility: Donor currently ineligible for OPTN KPD Pilot Program (e.g. incomplete data, incomplete work-up, etc.)
Candidate Inactive: Donor is temporarily inactive because candidate is temporarily inactive
Medical Non-Compliance: Donor temporarily inactive due to medical non-compliance
Donor Choice: Donor temporarily inactive due to donor choice
Insurance Issues: Donor temporarily inactive due to insurance issues
Operational Issues: Donor temporarily inactive due to operational issues (e.g. physician/surgeon unavailable, heavy workload at centers, etc.)
Temporarily medically unsuitable: Donor temporarily inactive because of temporary medical ineligibility (e.g. illness, pregnancy)
Transplant Pending: OPTN KPD Pilot Program exchange pending
Transplant Pending: Other KPD program exchange pending
Transplant Pending: Non-KPD transplant pending
Limit on number of donors associated with a candidate: Donor temporarily inactive because two other donors associated with the candidate are active
Bridge donor on hold from participating in match runs
Other, specify
Specify: If the Inactive reason is set to Other, the Specify field is required.
Removal reason: If the KPD status is set to Removed, the Removal reason field is required.
List of inactive reasons:
Removed: Donor chose to withdraw from OPTN KPD Pilot Program
Removed: Donor removed because paired candidate removed from OPTN Pilot Program
Removed: Donor unable to complete work-up
Removed: Donor not suitable according to program criteria
Removed: Donor too sick
Removed: Donor expired
Transplant: Donated through OPTN KPD Pilot Program
Transplant: Donated through other KPD program
Transplant: Non-KPD donation
Other, Specify
Specify: If the Removal reason is set to Other, the Specify field is required.
Home transplant center: The center code for the home transplant center. This field cannot be updated on this page.
History of diabetes:
No
Yes 0-5 years
Yes 6-10 years
Yes > 10 years
Yes Duration Unknown
Unknown
History of cancer:
No
Skin-squamous, basal cell
Skin-Melanoma
CNS tumor- Astrocytoma
CNS tumor- Glioblastoma multiforme
CNS tumor – Medullablastoma
CNS tumor – Neuroblastoma
CNS tumor – Angioblastoma
CNS tumor – Meningioma
CNS tumor – Other
Genitourinary – Bladder
Genitourinary – Uterine cervix
Genitourinary – Uterine body endometrial
Genitourinary – Uterine body choriocarcinoma
Genitourinary – Vulva
Genitourinary – Ovarian
Genitourinary – Penis, testicular
Genitourinary – Prostate
Genitourinary – Kidney
Genitourinary – Unknown
Gastrointestinal – Esophageal
Gastrointestinal – Stomach
Gastrointestinal – Small intestine
Gastrointestinal – Colo-rectal
Gastrointestinal – Liver & biliary tract
Gastrointestinal – Pancreas
Breast
Thyroid
Tongue/Throat
Larynx
Lung (including bronchial)
Leukemia/Lymphoma
Unknown
Other, specify
Specify: Enter the specific type of cancer. If History of cancer field is set to Other, this field is required. Valid range: 1–100 alphanumeric characters.
History of hypertension:
No
Yes 0-5 years
Yes 6-10 years
Yes > 10 years
Yes Duration Unknown
Unknown
Compliant with treatment:
Yes
No
Unknown
Number of medications for hypertension that the donor is on: This field is required for eligibility on the match.
0
1
2
3
4+
Please indicate the type of anti-hypertension medication and dosage: Alphanumeric. This field is required if the number of medications for hypertension is set to 1, 2, 3 or 4+.
Please indicate how long the donor has been on medication for hypertension:
Alphanumeric. This field is required if the number of medications for hypertension is set to 1, 2, 3, or 4+.
History of coronary artery disease (CAD):
Yes
No
Unknown
Previous gastrointestinal disease:
Yes
No
Unknown
Cigarette use (>20 pack years) ever:
Yes
No
Unknown
Cigarette use continued in last 6 months:
Yes
No
Unknown
Heavy alcohol use (2+ drinks/day):
Yes
No
Unknown
I.V. drug usage:
Yes
No
Unknown
According to the OPTN policy currently in effect, does the donor have risk factors for blood-borne disease transmission?:
Yes
No
Unknown
Abdominal trauma/surgery:
Yes
No
Unknown
Number of arteries: Enter the number of arteries (value must be between 1–9).
Number of veins: Enter the number of veins (values must be between 1–9).
Ureter:
Single
Double
Triple
Unknown
Home transplant center: The center code for the home transplant center. This field cannot be updated on this page.
Was 24-hour blood pressure monitor used?: This field is required for eligibility on the match run.
Yes
No
If Yes is entered for Was 24-hour blood pressure monitor used?, the following fields are required:
Blood pressure systolic (average of 24-hour period): Whole number between 0 and 300. This field is required for eligibility on the match run.
Blood pressure diastolic (average of 24-hour period): Whole number between 0 and 200. This field is required for eligibility on the match run.
Blood pressure date start (start of 24-hour period): Date when the 24-hour period began. MM/DD/YYYY format. This field is required for eligibility on the match run.
If No is entered for Was 24-hour blood pressure monitor used?, the following fields are required:
Blood pressure systolic 1: Whole number between 0 and 300. This field is required for eligibility on the match run.
Blood pressure diastolic 1: Whole number between 0 and 200. This field is required for eligibility on the match run.
Blood pressure date 1: Date when the blood pressure was taken. Format: MM/DD/YYYY. This field is required for eligibility on the match run.
Blood pressure systolic 2: Whole number between 0 and 300. This field is required for eligibility on the match run.
Blood pressure diastolic 2: Whole number between 0 and 200. This field is required for eligibility on the match run.
Blood pressure date 2: Date when the blood pressure was taken. MM/DD/YYYY format. This field is required for eligibility on the match run.
Was a stress test performed?:
Yes
No
Unknown
Enter either the donor's GFR or Creatinine Clearance value.
Date: MM/DD/YYYY format. This field is required for eligibility on the match run.
Creatinine clearance (24 hours urine collection) (mL/min): Whole number between 50 and 200. This field is required for eligibility on the match run.
Date: Date in MM/DD/YYYY format. This field is required for eligibility on the match run.
GFR (isotopic method) (mL/min/1.73m2): Whole number. This field is required for eligibility on the match run.
HbA1c (%): Number between 2 and 15 and its corresponding date in MM/DD/YYYY format.
Oral glucose tolerance test (OGTT): Whole number between 5 and 500.
Method: Method by which the OGTT was administered.
Fasting
1-hour
2-hour
Date: Oral glucose tolerance test date in MM/DD/YYYY format.
Microalbumin: Number between 15 and 300 and corresponding date in M/DD/YYYY format.
Urine protein-to-creatinine ratio: Number between 0 and 3 and corresponding date in MM/DD/YYYY format.
24 hour urine protein: Number between 0 and 3000 and corresponding date in MM/DD/YYYY format.
Date: Date of the urinalysis in MM/DD/YYYY format.
Color: KPD donor urine color. Alphanumeric field.
Appearance: KPD donor urine appearance. Alphanumeric field.
pH: Whole number between 5 and 10.
Specific gravity: Number between 1 and 1.5.
Protein:
Positive
Negative
Glucose:
Positive
Negative
Blood:
Positive
Negative
RBC:
Positive
Negative
WBC:
Positive
Negative
Epith (%):
Positive
Negative
Casts:
Positive
Negative
Bacteria:
Positive
Negative
Leukocyte esterase:
Positive
Negative
Date: Date in MM/DD/YYYY format.
Na (mEq/L): Whole number between 0 and 99999.
K+ (mmol/L): Number between 0 and 999.
Cl (mmol/L): Whole number between 0 and 9999.
CO2 (mmol/L): Number between 0 and 999.
BUN (mg/dL): Whole number between 0 and 9999.
Creatinine (mg/dL): Number between 0 and 999.
Glucose (mg/dL): Whole number between 0 and 9999.
Total bilirubin (mg/dL): Number between 0 and 9999.
Direct bilirubin (mg/dL): Number between 0 and 9999.
Indirect bilirubin (mg/dL): Number between 0 and 9999.
SGOT AST (u/L): Whole number between 1 and 36000.
SGPT ALT (u/L): Whole number between 1 and 50000.
Alkaline phosphatase (u/L): Whole number between 0 and 9999.
GGT (u/L): Whole number between 0 and 9999.
LDH (u/L): Whole number between 0 and 99999.
Albumin (g/dL): Number between 0 and 999.
Total protein (g/dL): Number between 0 and 999.
Prothrombin (PT) (seconds): Number between 0 and 9999.
INR: Number between 0 and 999.
PTT (seconds): Number between 0 and 9999.
Serum amylase (u/L): Number between 0 and 9999.
Serum lipase (u/L): Number between 0 and 9999.
Date: Date in MM/DD/YYYY format. If you enter a date, you must enter CBC values.
WBC (thous/mcL): Number between 1 and 99.
RBC (mill/mcL): Number between 1 and 99.
HgB (g/dL): Number between 1 and 99.
Hct (%): Number between 0 and 99.
Plt (thous/mcL): Whole number between 0 and 999.
Bands (%): Whole number between 0 and 99.
For a donor to be eligible for matches, required serologies must be either Positive or Negative.
Anti-CMV: This field is required for eligibility on the match run.
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
EBV
(VCA) (IgG):
This field is required
for eligibility on the match
run.
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
HBsAg: This field is required for eligibility on the match run.
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
Anti-HBcAb: This field is required for eligibility on the match run.
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
HBsAb:
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
Anti-HCV:
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
Anti-HIV I/II:
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
Anti-HTLV I/II:
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
RPR/VDRL:
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
EBNA:
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
EBV (VCA) (IgM):
Positive
Negative
Unknown
Not Done
Indeterminate
Pending
Please select test or attachment: This field is required.
Test
Attachment
Test type: This field is required.
Test date: Date of the test in MM/DD/YYYY format.
Diagnostic evaluation/comments: Alphanumeric. 1–5000 characters.
Attach medical image:
Yes
No
Description: Enter a description of the image. This field is required.
Select file: Click Browse to search for the file on your computer and select it. This field is required.
Please select test or attachment: This field is required.
Test
Attachment
Description: Description of the attachment you wish to attach. Alphanumeric format. This field is required.
Select File: This field is required if Attachment is selected for Please select test or attachment field.
Reason deleted: Reason the attachment was deleted. Alphanumeric. This field is required when deleting an attachment.
Home transplant center: The center code for the home transplant center displays. This field cannot be updated on this page.
A: KPD Donor A antigens. Values for both fields are required for eligibility on the match run.
B: KPD Donor B antigens. Values for both fields are required for eligibility on the match run.
BW4: KPD Donor BW4 antigen. This field is required for eligibility on the match run.
BW6: KPD Donor BW6 antigen. This field is required for eligibility on the match run.
C: KPD Donor C antigens. Values for both fields are required for eligibility on the match run.
DR: KPD donor DR antigens. Values for both fields are required for eligibility on the match run.
DR51: KPD donor DR51 antigen. This field is required for eligibility on the match run if corresponding unacceptable antigens are reported.
DR52: KPD donor DR52 antigen. This field is required for eligibility on the match run if corresponding unacceptable antigens are reported.
DR53: KPD donor DR53 antigen. This field is required for eligibility on the match run if corresponding unacceptable antigens are reported.
DQB1: KPD donor DQB1 antigens. Values for both fields are required for eligibility on the match run.
DQA1: KPD donor DQA1 antigens from both drop-down lists. Values for both fields are
required for eligibility on the match run.
DPB1: KPD donor DPB1 antigens. Values for both fields are required for eligibility on the match run.
DPA1: KPD donor DPA1 antigens. Values for both fields are required for eligibility on the match run.
Note: For ambiguities involving “G” alleles, you should report the lowest member of the “G” allele string. For example, if your lab receives a 04:02/105:01 typing result, you should report 04:02.
Home transplant center: The center code for the home transplant center. This field cannot be updated on this page.
Donor willing to travel?: This field is required for eligibility on the match run.
Yes
No
If Yes, to which center(s) is the donor willing to travel?: This field is required if Donor willing to travel field is set to Yes.
Is the donor willing to have his or her kidney shipped?: This field is required for eligibility on the match run.
Yes
No
This donor can ONLY donate his or her following kidney: This field is required for eligibility on the match run.
Right kidney
Left kidney
Either kidney
Pair and center willing to participate in a 3-way match?: This field is required for eligibility on the match run.
Yes
No
Pair and center willing to participate in a chain (not as a bridge donor)?: This field is required for eligibility on the match run.
Yes
No
If matched with an opportunity to be a bridge donor, does the donor consent and the center agree to continue the chain as a bridge donor?: This field is required for eligibility on the match run.
Yes
No
Last name: KPD donor last name. This field is read-only.
First name: KPD donor first name. This field is read-only.
Middle initial: KPD donor middle initial. This field is read-only.
ABO: KPD donor ABO. This field is required.
O
A
A1
A2
B
AB
A1B
A2B
Age: KPD donor age. This field is read-only.
Gender: KPD donor gender. This field is read-only.
Male
Female
First user ABO entry: The name of the first person to enter the KPD donor’s ABO displays. This field is read-only.
IF a living donor is subtyped and is found to be A2 or A2B, then a second subtype test must be completed. If the ABO subtype is successfully verified, the verified ABO subtype will be used for match runs. If the ABO subtype is unverified, the verified primary ABO will be used for match runs.
Last name: KPD donor last name. This field is read-only.
First name: KPD donor first name. This field is read-only.
Middle initial: KPD donor middle initial. This field is read-only.
ABO: KPD donor ABO. This field is required.
O
A
A1
A2
B
AB
A1B
A2B
Age: KPD donor age. This field is read-only.
Gender: KPD donor gender. This field is read-only.
Male
Female
First ABO subtype user: The name of the first person to enter the KPD donor’s ABO displays. This field is read-only.
Home transplant center: KPD donor’s home transplant center code and name. This field is required.
KPD donor ID: Unique identifier for the KPD donor generated by the system. This field is read-only.
Donor name: KPD donor name. This field is read-only.
Match run date donor became a bridge donor: Date value determined by system. Format: MM/DD/YYYY. This field is read-only.
Bridge donor on hold: If box is checked the donor will not be included in match runs. If box is unchecked, the donor will be included in match runs. This field is optional.
Access bridge donor record: link
Exchange number: Unique identifier for the exchange. System generated. This field is read-only.
When the bridge donor status is changed from pending bridge donor to donating to WaitlistSM on the Manage Bridge Donor Record screen the donor is removed from the Pending Bridge Donors section and displays in the Donating to WaitlistSM section.
Home transplant center: Transplant center code and name. This field is required.
KPD donor ID: Unique identifier for KPD donor generated by the system. This field is read-only.
Donor name: KPD donor name. This field is read-only.
Bridge donor status: This field is required.
Pending Bridge Donor
Pending Exchange Accepted
Donating to WaitlistSM
Declined to Donate
Bridge donor status date: Pre-filled with current date. If bridge donor status field is changed, the bridge donor status date must be reentered. Date cannot be a future date. Date must not be prior to Match Run date, when donor became a bridge donor. This field is required.
Bridge donor on hold: If box is checked, the donor will not be included in match runs. If box is unchecked, the donor will be included in match runs. This field is optional.
KPD donor status: This field is read-only.
Active
Inactive
Removed
Match run date donor became a bridge donor: Date value determined by system. This field is read-only.
Exchange number: Unique identifier for the exchange generated by system. This field is read-only.
Bridge donor status declined to donate reasons: This field is required if bridge donor status is set to decline to donate.
Life circumstances have changed:
Employment
School
Social
Family Situation
Other
Medical condition has changed:
Pregnancy
Hypertension
Diabetes/pre-diabetes
Increase in BMI
Kidney Diseases/Stones
Cancer
Other
Other reasons:
Paired recipient had a poor transplant outcome
Wait was too long after paired recipient was transplanted
Unknown donor did not disclose
Other
Enter Comments: This field is required if Other or Unknown is selected. Alphanumeric format.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Kidney Paired Donation Donor Registration_Instructions |
| File Modified | 0000-00-00 |
| File Created | 2023-07-29 |