BACKGROUND: Highly sensitized (HS) patients (>85% panel-reactive antibodies) have a lower chance of receiving a donor kidney. Within Eurotransplant the Acceptable Mismatch (AM) program was developed to increase the chances of HS patients to receive a crossmatch-negative donor kidney. The standard crossmatch in the AM program is based on complement-dependent cytotoxicity. METHODS: In this study we wanted to determine the clinical relevance of human leukocyte antigen donor-directed antibodies (DDA) detected by the single antigen (SA) bead technique, in the pretransplant sera of HS patients transplanted in our center through the Eurotransplant AM program. RESULTS: From 34 AM patients, 27 were transplanted with 1 to 5 mismatches and 7 received a 0-mismatched graft. From the mismatched patients, retrospectively, 13 proved to possess pretransplant DDA by SA whereas 14 did not. No antibodies were found in the 0-mismatched group. Comparison of the DDA+ and DDA- patients in the human leukocyte antigen-mismatched donor/recipient combinations revealed a trend to an earlier and higher number of rejection episodes in DDA+ patients (P=0.08). No detrimental effect of DDA on graft survival was observed. CONCLUSIONS: This single-center study showed that in the AM program DDA detected by SA, and not by less-sensitive methods, may be related to acute rejection episodes but is not detrimental to long-term graft outcome. These findings question the increasing use of more-sensitive screening techniques for the allocation of organs.