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Consideration of a patient's state of prior sensitization and the effects of histocompatibility antigen matching are critical to avoid antibody-mediated rejection and improve the long-term outcome of transplantation. Since there are many reviews of transplantation immunology in the literature and the mechanism of allograft destruction is outlined in Chapter 7, this chapter will concentrate only on those immunological considerations that affect pretransplant histocompatibility testing and recipient selection for thoracic organ transplantation. When applicable, prospects for developing new procedures to circumvent antibodies in the recipient will be discussed, as will new technologies in histocompatibility testing. The discussion will be divided into four topics: (a) the importance of donor-recipient ABO and Rh blood group compatibility, (b) human leukocyte antigen (HLA) typing and the role of HLA matching, (c) evaluation of recipients for prior sensitization and the importance of the lymphocytotoxic crossmatch, and (d) the effect of pretransplant blood transfusion in recipients of cardiac allografts. [ABSTRACT FROM AUTHOR]