DECEASED DONOR INFORMATION
INFORMATION NEEDED BY RENAL TRANSPLANT: Zero antigen mismatch: Y / N UNET match run ID:
PAK/SPK: Y / N
Estimated time of donor OR:
INFORMATION NEEDED BY THE LIT
Donor Name:
Date:
Age:
PNTB#:
UNOS#:
DOB:
Sex:
ABO:
CMV:
Race:
Donor Type: (circle) SCD / ECD / DCD / en bloc
CDC Risk: (circle) CDC high risk behavior ≤30 days (all OHSU & VA pts to be ruled out) / CDC high risk behavior >30 days
Creatinine: leave blank if greater than 1.5*
Creatinine Date:
Creatinine Time:
(LIT: *1.5 or greater, you must confirm hasn’t dropped when the match is run)
Donor Height:
Donor Weight:
Cause of death:
Double Allocation? Yes / No
History of Hypertension? Yes / No
If Yes, how long
or Unknown Duration
History of Diabetes? Yes / No
If Yes, how long
or Unknown Duration
Are the red top tubes (serum) pre-transfusion? Yes / No / Unknown
Are the yellow and lavender top tubes (whole blood) pre-transfusion? Yes / No / Unknown
# of transfused units of whole blood or packed red blood cells:
HLA Type: HLA-A
HLA-DR
HLA-B
HLA-DRW
HLA-BW
HLA-DQ
HLA-CW
INFORMATION NEEDED FROM PNTB
Fax number for LIT to send PNTB reports:
PNTB contact number: (800) 344-8916
Cause of Death:
Donor Clamp Date / Time:
OPO:
Solution:
Left Kidney Anatomy:
Right Kidney Anatomy:
PNTB Coordinator:
/
Warm Time:
Donor Age Categories
Donor Condition
CVA + HTN + Creat>1.5
CVA + HTN
CVA + Creat>1.5
HTN + Creat>1.5
CVA
HTN
Creatinine>1.5
None of the above
Document1
50-59
X
X
X
X
> 60
X
X
X
X
X
X
X
X
Definition of Expanded Criteria Donor
X = Expanded Criteria Donor
CVA = CVA was cause of death
HTN = history of hypertension at any ti me
Creat>1.5 = creatinine >1.5 mg/dl
Maximum Number of Transfusions
for a Peripheral Blood Work Up
Weight
Kg
Lb
<10
<22
10-30
22-66
31-50
67-110
51-70
111-154
>70
>154
# transfusions
1
2
3
4
5