Recipient Inclusion / Exclusion

*Note: All inclusion criteria need to be answered yes and all exclusion criteria need to be answered no or the participant is not eligible for participation.

Timeline requirements for this form are as follows:
Assessment timeframe: At the time of eligibility assessment
Submission timeframe:

Recipient Inclusion Criteria

Is the patient 18-65 years old?
Indicate if the participant’s age is greater than or equal 18 and less than or equal to 65 years old?’

• Yes
• No
  

Is the patient receiving a donor related transplant at Stanford university Medical Center or Northwestern Medicine?
Indicate if the participant is receiving a donor related transplant at Stanford university Medical Center or Northwestern Medicine.

• Yes
• No
  

Is the patient (males and females of reproductive potential) willing to agree to practice a reliable form of contraception for at least 1-year post-transplant?
Indicate if the participant is willing to agree to practice a reliable form of contraception for at least 1-year post-transplant. A reliable form of contraception includes: (enter forms of accepted contraception). If the participant is not of reproductive potential, answer ‘Not applicable’.

• Yes
• No
• Not applicable
  

Has the Kidney Transplant Study informed consent for been signed by the patient or legal guardian?
Indicate if the patient (or legal guardian) signed the Kidney Tolerance consent form. If “no” is indicated and the form is processed, the patient will not be enrolled in the study.

• Yes
• No
  

Recipient Exclusion criteria

Does the patient have an HLA-matched sibling donor available?
Indicate if the participant has an HLA-matched living sibling donor available. The participant should have a haplotype matched (minimum single HLA-DR and HLA-A or B match) donor.

• Yes
• No
  

Has the patient had previous treatment with rabbit ATG or a known allergy to rabbit proteins?
Indicate if the participant has had previous treatment with rabbit antithymocyte globulin (ATG) or has a known allergy to rabbit proteins. Rabbit ATG is rabbit-derived antibodies against human T cells, which is used in the prevention and treatment of acute rejection in organ transplantation.

• Yes
• No
  

Does the patient have a known contraindication to administration of rabbit ATG or radiation?
Indicate if the participant has a known contraindication to administration of rabbit ATG or radiation. A contraindication is a specific situation in which a drug, procedure, or surgery that should not be used because it may be harmful to the person.

• Yes
• No
  

Does the patient have a history of malignancy with the exception of non-melanoma skin malignancies?
Indicate if the participant has a history of malignancy. This does not include non-melanoma skin malignancies.

• Yes
• No
  

Is the patient pregnant or breast feeding?
Indicate if the participant is pregnant or breast feeding.

• Yes
• No
• Not applicable, male or female of non-childbearing potential
  

Does the patient have serological evidence of HIV, Hepatitis B (Hep BsAg+), or Hepatitis C infection?
Indicate if the participant has serological evidence of HIV, Hepatitis B (Hep BsAg+), or Hepatitis C.

• Yes
• No
  

Has the patient moved from EBV positive to EBV negative?
Indicate if the participant has moved from EBV positive to EBV negative.

• Yes
• No
  

Does the patient have Leukopenia (with a white blood cell count less than 3000/mm ³ ) or thrombocytopenia (with a platelet count less than 100,000/mm ³ )?
Indicate if the participant has Leukopenia (white blood cell count less than 3000/mm ³ ) or thrombocytopenia (platelet count less than 100,000/mm ³ ).

• Yes
• No
  

Does the patient have PRA greater than 80% or demonstration of historic and/or current donor specific antibody (DSA)?
Indicate if the participant has a panel-reactive antibody (PRA) greater than 80% or demonstration of historic and/or current donor specific antibody (DSA). PRA is a group of antibodies in a test serum that are reactive against any of several known specific antigens in a panel of test cells or purified HLA antigens from cells.

• Yes
• No
  

Has the patient had a prior organ transplantation?
Indicate if the participant had a prior organ transplantation.

• Yes
• No
  

Does the patent have high risk of primary kidney disease recurrence (i.e. FSGS)?
Indicate if the participant has a high risk of primary kidney disease recurrent. This can include FSGS or Focal segmental glomerulosclerosis. FSGS is a disease in which scar tissue develops on the parts of the kidneys that filter waste from the blood (glomeruli).

• Yes
• No
  

Does the patient have advanced coronary or vascular disease?
Indicate if the participant has advanced coronary or vascular disease.

• Yes
• No
  

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CIBMTR® (Center for International Blood and Marrow Transplant Research) is a research collaboration between the Medical College of Wisconsin and NMDP.