| Kidney Minimum Acceptance Criteria |
| Fields to be completed by members |
|
|
|
| Form Section |
Field Label |
Notes |
| Donor History & Management |
What is the maximum donor age your center will consider? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with an unknown cause of death? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a history of cancer (other than a primary brain tumor) - less than one year ago? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a history of cancer (other than a primary brain tumor) - 1 to 5 years ago? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a history of cancer (other than a primary brain tumor) - 6 to 10 years ago? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a history of cancer (other than a primary brain tumor) - more than ten years ago? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a primary brain tumor that is - malignant (i.e. Glioblastoma, Astrocytoma, Medulloblastoma)? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a primary brain tumor that is - non-malignant (i.e. Meningioma, Ependymoma, Neuroblastoma)? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with meningitis as the cause of death? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with any of the following exposures within the last 30 days - sex (i.e., any method of sexual contact, including vaginal, anal, and oral) with a person known or suspected to have HIV, HBV, or HCV infection |
|
| Donor History & Management |
Will your center consider kidneys from a donor with any of the following exposures within the last 30 days - man who has had sex with another man |
|
| Donor History & Management |
Will your center consider kidneys from a donor with any of the following exposures within the last 30 days - sex in exchange for money or drugs |
|
| Donor History & Management |
Will your center consider kidneys from a donor with any of the following exposures within the last 30 days - sex with a person who had sex in exchange for money or drugs |
|
| Donor History & Management |
Will your center consider kidneys from a donor with any of the following exposures within the last 30 days - drug injection for nonmedical reasons |
|
| Donor History & Management |
Will your center consider kidneys from a donor with any of the following exposures within the last 30 days - sex with a person who injected drugs for non-medical reasons |
|
| Donor History & Management |
Will your center consider kidneys from a donor with any of the following exposures within the last 30 days - incarceration (confinement in jail, prison, or juvenile correction facility) for ≥ 72 consecutive hours |
|
| Donor History & Management |
Will your center consider kidneys from a donor with any of the following exposures within the last 30 days - child breastfed by a mother with HIV infection |
|
| Donor History & Management |
Will your center consider kidneys from a donor with any of the following exposures within the last 30 days - child born to a mother with HIV, HBV, or HCV infection |
|
| Donor History & Management |
Will your center consider kidneys from a donor with any of the following exposures within the last 30 days - unknown medical or social history |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a positive result from any of the following infectious disease tests - Hepatitis B Surface Antigen? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a positive result from any of the following infectious disease tests - Hepatitis B Core Antibody with no IGG/IGM testing? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a positive result from any of the following infectious disease tests - Hepatitis B Core Antibody with IGM testing? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a positive result from any of the following infectious disease tests - HBV NAT? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a positive result from any of the following infectious disease tests - Anti-HCV? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a positive result from any of the following infectious disease tests - HCV NAT? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a positive result from any of the following infectious disease test - HTLV I or II? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with a positive result from any of the following infectious disease tests - Syphilis? |
|
| Donor History & Management |
What is the maximum Levophed dosage and duration your center will consider? - mcg/kg/in |
|
| Donor History & Management |
What is the maximum Levophed dosage and duration your center will consider? - hours |
|
| Donor History & Management |
Averaging the Dopamine dosage over the last 12 hours, what is the highest dosage your center will consider? - mcg/kg/min |
|
| Donor History & Management |
What is the maximum amount of warm ischemic time your center will consider? - minutes |
|
| Donor History & Management |
Will your center consider kidneys from a donor with - signs of infection that include elevated WBC (final > 17000) and temperature (greater than or equal to 100 degrees for 12 hours)? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with - a perforated colon, small bowl, or stomach? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with DIC that was - corrected? |
|
| Donor History & Management |
Will your center consider kidneys from a donor with DIC that was - not corrected? |
|
| Donor History & Management |
For the following durations, will your center consider an adult kidney donor with prolonged hypotension (<70 mm/Hg systolic) - less than 1 hour? |
|
| Donor History & Management |
For the following durations, will your center consider an adult kidney donor with prolonged hypotension (<70 mm/Hg systolic) - 1 to 3 hours? |
|
| Donor History & Management |
For the following durations, will your center consider an adult kidney donor with prolonged hypotension (<70 mm/Hg systolic) - 4 to 8 hours? |
|
| Donor History & Management |
For the following durations, will your center consider an adult kidney donor with prolonged hypotension (<70 mm/Hg systolic) - 9 to 12 hours? |
|
| Donor History & Management |
For the following durations, will your center consider an adult kidney donor with prolonged hypotension (<70 mm/Hg systolic) - more than 12 hours? |
|
| Donor History & Management |
What is the minimum donor creatinine clearance level either measured or estimated based on serum creatinine upon donor's admission your center will consider? - ml/min corrected to 1.73M2 |
|
| Anatomy |
Will your center consider an adult kidney donor with any of these abnormalities - horseshoe kidney? |
|
| Anatomy |
Will your center consider an adult kidney donor with any of these abnormalities - polycystic kidney disease? |
|
| Anatomy |
Will your center consider an adult kidney donor with any of these abnormalities - infarcted kidney (>20%)? |
|
| Anatomy |
Will your center consider an adult kidney donor with any of the abnormalities - decapsulated kidney (complete)? |
|
| Anatomy |
Will your center consider a kidney from a donor with soft plaque in the renal artery described as - mild |
|
| Anatomy |
Will your center consider a kidney from a donor with soft plaque in the renal artery described as - moderate |
|
| Anatomy |
Will your center consider a kidney from a donor with soft plaque in the rental artery described as - severe |
|
| Anatomy |
Will your center consider a kidney from a donor with hard plaque in the renal artery described as - mild |
|
| Anatomy |
Will your center consider a kidney from a donor with hard plaque in the renal artery described as - moderate |
|
| Anatomy |
Will your center consider a kidney from a donor with hard plaque in the renal artery described as - severe |
|
| Anatomy |
Will your center consider a kidney from a donor with hard plaque in the renal artery described as - ulcerative |
|
| Anatomy |
Based on the length of the kidney, will your center consider a donor kidney that is 2 or more centimeters smaller than the kidney on the opposite side? |
|
| Donation after Circulatory Death (DCD) |
Will your center consider a kidney recovered from - a controlled DCD donor? |
|
| Donation after Circulatory Death (DCD) |
Will your center consider a kidney recovered from - an uncontrolled DCD donor? |
|
| Donation after Circulatory Death (DCD) |
Will your center consider a kidney recovered from - a DCD donor with no kidney biopsy report? |
|
| Donation after Circulatory Death (DCD) |
What is the maximum duration of hypotension (<90 systolic) prior to cardiac arrest that your center will consider? - minutes |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With a history of hypertension and compliant with medication? < 45 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With a history of hypertension and compliant with medication? 45-54 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With a history of hypertension and compliant with medication? 55-64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With a history of hypertension and compliant with medication? > 64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With a history of hypertension and period(s) of non-compliance within the last 5 years? < 45 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With a history of hypertension and period(s) of non-compliance within the last 5 years? 45-54 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With a history of hypertension and periods(s) of non-compliance within the last 5 years? 55-64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With a history of hypertension and period(s) of non-compliance within the last 5 years? > 64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. Who is an insulin dependent diabetic? < 45 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. Who is an insulin dependent diabetic? 45-54 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. Who is an insulin dependent diabetic? 55-64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. Who is an insulin dependent diabetic? > 64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With diabetes and requires oral medication? < 45 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With diabetes and requires oral medication? 45-54 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With diabetes and requires oral medication? 55-64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With diabetes and requires oral medication? > 64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With CPR? < 45 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With CPR? 45-54 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With CPR? 55-64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. With CPR? > 64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. Without CPR? < 45 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. Without CPR? 45-54 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. Without CPR? 55-64 years |
|
| Age Specific (Donor Age) |
Identify the duration for which your center will consider donor kidneys for the specified circumstance. Without CPR? > 64 years |
|
| Age Specific (Donor Age) |
What is the maximum acceptable peak serum creatinine level? < 45 years |
|
| Age Specific (Donor Age) |
What is the maximum acceptable peak serum creatinine level? 45-54 years |
|
| Age Specific (Donor Age) |
What is the maximum acceptable peak serum creatinine level? 55-64 years |
|
| Age Specific (Donor Age) |
What is the maximum acceptable peak serum creatinine level? > 64 years |
|
| Age Specific (Donor Age) |
What is the maximum cold ischemic time (based on arrival time) on cold storage? < 45 years |
|
| Age Specific (Donor Age) |
What is the maximum cold ischemic time (based on arrival time) on cold storage? 45-54 years |
|
| Age Specific (Donor Age) |
What is the maximum cold ischemic time (based on arrival time) on cold storage? 55-64 years |
|
| Age Specific (Donor Age) |
What is the maximum cold ischemic time (based on arrival time) on cold storage? > 64 years |
|
| Age Specific (Donor Age) |
What is the maximum acceptable percentage of sclerotic glomeruli for a biopsied kidney? < 45 years |
|
| Age Specific (Donor Age) |
What is the maximum acceptable percentage of sclerotic glomeruli for a biopsied kidney? 45-54 years |
|
| Age Specific (Donor Age) |
What is the maximum acceptable percentage of sclerotic glomeruli for a biopsied kidney? 55-64 years |
|
| Age Specific (Donor Age) |
What is the maximum acceptable percentage of sclerotic glomeruli for a biopsied kidney? > 64 years |
|
|
|
|
|
|
|
| OMB No. 0915-0157; Expiration Date: XX/XX/20XX |
|
|
| PUBLIC BURDEN STATEMENT: |
|
|
| The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 0.27 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. |