Recipient Center Responsibilities After Remote Donor Approval
Even after a remote donor center approves a donor, the recipient's transplant center must independently verify donor-recipient immunologic compatibility through crossmatch testing and HLA antibody assessment to prevent hyperacute rejection and ensure acceptable transplant outcomes.
Critical Immunologic Compatibility Testing
The recipient's center bears ultimate responsibility for confirming immunologic compatibility, regardless of the remote donor center's approval:
Mandatory Crossmatch Requirements
A recipient-donor crossmatch must be performed using flow cytometry or an enhanced complement-dependent cytotoxicity (CDC) assay (such as anti-human globulin-enhanced CDC) to detect IgG antibodies against donor HLA antigens 1
A positive crossmatch with IgG antibodies to HLA antigens is an absolute contraindication to transplantation, whether detected on T cell or B cell targets 1
Multiple recipient sera must be tested, including historically reactive sera (highest PRA), current sera, and immediately pre-transplant sera to identify any immune memory that could trigger accelerated rejection 1
IgM-positive crossmatches are not contraindications and should be distinguished from clinically relevant IgG reactivity through heat or chemical treatment 1
HLA Typing and Antibody Assessment
Complete HLA typing for both MHC Class I (A, B, C) and Class II (DP, DQ, DR) must be performed on both donor and recipient, with assessment of donor-specific anti-HLA antibodies in the recipient 1
Highly sensitized recipients require particular scrutiny, as they may have antibodies detectable only by more sensitive methods like flow cytometry that could still cause rejection 1
ABO Blood Type Verification
Independent ABO blood typing must be confirmed at the recipient's center, even if performed remotely, as this is a fundamental compatibility requirement 1
Blood group A subtype testing should be performed when the recipient has anti-A antibodies 1
Recipient-Specific Medical Suitability Assessment
Beyond immunologic testing, the recipient's center must determine:
Surgical Risk Assessment
The recipient's center must evaluate whether the donor kidney is medically suitable for their specific recipient, considering factors like donor kidney quality, vascular anatomy, and recipient surgical risk that may differ from the remote center's assessment 1
While a cardiologist or other specialist may "clear" a donor for surgery, the recipient's transplant team must independently determine if this represents acceptable risk for their specific recipient in the context of an optional living donor procedure 1
Incompatibility Management Planning
If ABO or crossmatch incompatibility exists, the recipient's center must have an effective incompatibility management strategy in place before proceeding, as transplantation should only occur with such protocols 1
Recipients must be counseled about center-specific outcomes for incompatible transplantation, as these vary based on institutional expertise 1
Logistical and Follow-Up Arrangements
The recipient's center must establish clear operational protocols:
Follow-Up Care Coordination
The recipient's center must determine through mutual agreement whether donor follow-up will occur at the surgical center or recipient's center, resolving this before donation 2
Financial arrangements must be established to ensure the donor does not incur out-of-pocket costs for recommended follow-up care, regardless of geographic separation 2
The donor's ability to cover costs associated with repeated returns to either center must be discussed and resolved prospectively 2
Independent Donor Team Verification
The recipient's center must verify that an independent donor team entirely separate from the recipient's team conducted the evaluation, as required by transplantation standards 2, 3
A detailed on-site psychosocial evaluation must have occurred at the surgical center, not just medical clearance 2, 3
Common Pitfalls to Avoid
Do not assume immunologic compatibility based solely on the remote center's approval—independent crossmatch testing is mandatory 1
Do not proceed without establishing clear follow-up arrangements that account for geographic separation between surgical and recipient centers 2
Do not rely on standard NIH-CDC crossmatching alone—enhanced methods (AHG-CDC or flow cytometry) are required to detect clinically relevant antibodies 1
Do not ignore historically reactive sera—testing only current sera may miss immune memory that causes accelerated rejection 1