BACKGROUND In search of an alternative screening technique, we compared complement-dependent cytotoxicity (CDC) with PRA-STAT, a commercially available enzyme-linked immunosorbent assay (ELISA). METHODS A total of 188 pre- and posttransplant sera from 50 renal allograft recipients were tested with both methods. RESULTS A significant correlation was found between both methods. Discrepant results could be explained by the fact that PRA-STAT detects both HLA class I and II antibodies (while CDC with peripheral blood lymphocytes as target cell detects mainly HLA class I reactivity), by the presence of IgM antibodies (which are not detected by the IgG-specific ELISA test), and by CDC "false-positive" results due to antibody rejection treatment. The clinical relevance of antibodies detected by PRA-STAT is suggested by the following. (a) In eight patients, donor-specific HLA antibodies detected by PRA-STAT (but not seen by CDC) resulted in severe rejection episodes, which led to graft loss in four cases. In all but one patient, antibodies were directed against class II or mixtures of class I and H antigens. Six patients with complications were shown to have developed de novo antibodies against DQ incompatibilities. (b) Half of the patients with a positive ELISA test at the moment of crossmatch experienced complications. Such patients are at a threefold higher risk of suffering from rejection episodes and/or graft loss than patients who are not sensitized (P<0.05, Fisher exact test). CONCLUSIONS Because PRA-STAT is very reproducible, detects both HLA class I and II antibodies, and is not influenced by rejection therapy, we consider it an additional tool for pre- and posttransplant monitoring of kidney allograft recipients.