Transplantation Immunology

Disorders of MHC
Major Histocompatibility Complex
Transplantation workups
Transplant recipient must be blood group antigen
(ABO) compatible with the donor and not have any
preformed anti-HLA (cytotoxic) antibodies in the
blood
Compatibility in both areas prevents hyperacute
transplantation reactions
Normally, these antibodies should not be present
unless the recipient has had a blood transfusion in the
past or has been pregnant and had a fetal-maternal
bleed during delivery and been exposed to paternal
antigens on the fetal cells

VIROLOGICAL ASSESSMENT
Both donor and recipient are tested for: VHB,
VHD, VHC, HIV 1/2, CMV, EBV, HSV 1 si 2, VZV,
HTLV 1/2 , rubella virus, toxoplasma gondii and
chlamydia.

Methods
Indirect diagnostic tests (serological)
Direct diagnostic tests, molecular biology tests
(PCR, RT-PCR).

HLA
Determines the fate of transplantation.
Plays a role in the control of cellular
interactions resposible for both cellular
and humoral immune responses.
Is associated with a variety of diseases.

HLA

IMMUNOGENETICS
1. Cross- match
- CDC
- ELISA

2. HLA Typing by molecular biology methods PCR

SSOP- sequence-specific oligonucleotide probe
hybridization (medium resolution) on solid membranes
SSP sequence-specific primers (high resolution) - EF
SBT allele SEQR (the highest available resolution)

3. Anti-HLA antibody detection and identification

- AHG CDC
- ELISA

Disorders of MHC
Major Histocompatibility Complex
Lymphocyte crossmatch
Used to screen recipient serum for anti-HLA antibodies
Recipients serum, complement and donor B
lymphocytes are mixed together in a test tube. Lysis
of donor lymphocytes is indicative of cytotoxic
antibodies in the recipients serum directed against
donor lymphocytes
The identity of these antibodies must then be
determined in order to find a suitable donor who is
negative for the corresponding HLA antigen(s).

Sample of cells or tissue

Combine DNA with sequencespecific primer fix for each

allele

Amplify by
PCR

DNA

80ng for Class I

40 ng for Class II

Importance of DNA Quality

100 ng Genomic DNA 1% Agarose Gel

Assign-SBT Resolves Ambiguities

Sequences are arranged in
layersMaster sequence

Patient result

Types of Transplants
Corneal
Best graft survival rate since the cornea is
avascular and the lymphatic drainage from the
eye is not as well developed as in other tissues
Associated with transmission of prionsCreukfeld-Jacob disease-Transmissible
spongiform encephalopathy; also has been
associated with amoebic transmission
(granulomatous amebic encephalitis)

Types of Transplants
Renal
Between living donors with a 2 haplotype match
= 90-95% 5 year survival
With a 1 haplotype match = 80% 5 year survival
Cadaver transplants between unrelated donors
is the most common type of transplantation.
Similar statistics to 1 haplotype match when
the recipient receives multiple blood
transfusions prior to the surgery (induces
tolerance to the allograft) and is placed on
immunosuppressive therapy

Types of Transplants
Liver
In adults with chronic active hepatitis or
cirrhosis
In children with biliary atresia
1 year survival rate is slightly greater
than 90%

Types of Transplants
Cardiac transplantation
In adults, used in patients with chronic
ischemic heart disease and congestive
cardiomyopathy
In children, endocardial fibroelastosis is
the usual indication
Endomyocardial biopsies are the best
means of diagnosing allograft rejection
Approximately 80% of transplants
survive 1 year

Types of Transplants
Bone marrow transplants
Used in the treatment of aplastic anemia,
leukemia and immunodeficiencies
Goal is to infuse donor marrow containing
pluripotential hematopoietic stem cells that will
eventually repopulate the lymphoid, erythroid,
myeloid, and megakaryocytic series in the
recipient.
GVH occurs in almost 2/3rds of cases
Increased incidence of CMV pneumonitis

Transplant Rejection
The chance of a sibling in a family having another
sibling with 0, 1, or 2 haplotype match is:
25% - 0 haplotype match
25% - 2 haplotype match
50% - 1 haplotype match
However, a 2 haplotype match is rarely
achieved due to crossovers between the
individual loci during meiosis when homologous
chromosomes line up close to each other

Transplant Rejection
Three types of transplant rejections
Hyperacute rejection
Acute rejection
Chronic rejection

Transplant Rejection
Hyperacute rejection:
occurs within minutes of attaching the allograft
to the recipients blood supply
Due to the presence of an ABO mismatch or
preformed cytotoxic antibodies in the host
against foreign HLA antigens in the donor
tissue (example; a blood group A recipient would
have anti-B IgM antibodies and would react
against a group B donor heart)
Hyperacute rejection is rare because ABO and
anti-HLA cytotoxic antibody screening is
performed prior to the surgery

Transplant Rejection
Acute rejection
Most common type of rejection encountered
Usually occurs within the first 3 months of the
transplantation
Involves cell-mediated and antibody-mediated
reactions. Cell-mediated has the greatest role in
rejection
The type II antibody-mediated hypersensitivity
produces a necrotizing vasculitis with subsequent
vessel damage and intravascular thrombosis

Transplant Rejection
Acute rejection
Vessel events can occur over a period of time
leading to fibrosis and vessel lumen obliteration
The cell-mediated component involves cytotoxic
T cells producing extensive interstitial
infiltrate in the graft with edema and damage
to the tissue (Type IV hypersensitivity)
Can be reversible with immunosuppressive drugs
such as cyclosporin A, corticosteroids, and
OKT3.

T-cell mediated rejection

Donors dendritic
cells + donors ag

Hosts effector
cells

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Antigen presentation

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Type IV Hypersensitivity
Cytotoxic T cells interact with class I antigens on nucleated cells
If the antigens are altered (virally infected cells, neoplastic cells) or the
cell is foreign to the host (transplant), the cytotoxic T cells will attach to
the cell membrane, release perforins and destroy the cell.
Examples: Acute and chronic transplant rejections; destruction of
hepatocytes infected by hepatitis B virus

Transplant Rejection
Chronic rejection
Irreversible
Occur over a period of months to years
Extensive fibrosis and loss of organ structure
characterize the histologic findings in the
transplant
Activated macrophages release growth factors that
stimulate fibroblasts to deposit collagen
There is also chronic ischemia secondary to
antibody-mediated damage to the vessels

Graft versus host (GVH) reaction

Transplantation of
immune competent
cells (E.g. bone
marrow)

Donors effector cells

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Graft versus Host Reactions

Potential complication in bone marrow and liver
transplants and in blood transfusions administered
to patients with T cell immunodeficiency
Donor lymphocytes produce interleukin-2
-->activation of NK cells (primary effector cells in
acute GVH reactions)-->lymphokine-activated NK
cells are called LAKs and produce extensive
epithelial cell necrosis in the biliary tract
(jaundice), skin (maculopapular rash), and GI tract
(diarrhea)

Graft versus Host Reactions

May progress into chronic GVH which
is marked by the presence of
extensive fibrosis
To lessen the risk of GVH, donor
tissue is pretreated with antithymocyte globulin to remove donor T
cells.
Cyclosporin A is used also

ID/CC

A 45 year old male with refractory acute myeloid

leukemia is brought to the emergency room with fever,
a generalized rash, jaundice, right upper quadrant pain,
severe diarrhea, and dyspnea; two months ago, he
underwent an apparently uncomplicated bone marrow
transplantation.

HPI

Prior to the transplant, he received radiotherapy and

chemotherapy as well as broad-spectrum antibiotics

PE

VS: normal blood pressure. PE: cachexia; moderate

dehydration; 2+ jaundice; violaceous and erythematous
macules as well as papules and bullae with scale
formation over extremities

Labs

Elevated IgE level. CBC/PBS: falling blood counts;

relative eosinophilia. Elevated direct serum bilirubin
and transaminases, no infectious agents on stool exam

Inhibition of rejection
Donor selection

Allograft
Living donor - Time for genotyping
Family relation
Monozygotic twin > sibling, parents,
Deceased donor
waiting lists
Xenografts
Genetic manipulation of donor
Humanized piglet

Manipulation of graft

Washing out and/or elimination of immuncompetent cells

Immuno-suppression

Inhibition of Cytokine production

Corticosteroids
Cyclosporin A -< IL-2
Blocking of lymph circulation

Antibodies against
MHC
IL-2R
CD3, CD4

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Transplant Rejection
Cyclosporin A inhibits CD4 helper T cell release of
interleukin-2 (blocks calcineurin) which stimulates
the proliferation of cytotoxic and helper T cells
Corticosteroids inhibit macrophage production of
interleukin-1 and tumor necrosis factor and are
cytotoxic to immature cortical derived thymocytes
OKT3 is a monoclonal antibody preparation that
attaches to the CD3 antigen receptor of T cells,
blocking their reaction with the graft

Transplant complications
Immunosuppressive therapy has increased the
incidence of:
Cervical cancer
Malignant lymphomas (immunoblastic)
Basal and squamous cell carcinomas of the skin
Squamous cell CA is the most common
overall malignancy
Other complications include infection and bone
marrow suppression

Fetus is an
allograft,
recognized and
tolerated by mother
(repeatedly)

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Physiology

Immunology

Fertilization

Transplantation

Pregnancy

Tolerance

Abortion

Early rejection

Birth

Rejection in time

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