TRANSPLANTATION
Transplantation immunology
and ABO incompatibility
Nina Plant
Peter Wood
Abstract
An allograft is tissue transplanted from another individual within the
same species. Mechanical trauma to a graft and recipient transplant
site along with graft-derived proinflammatory mediators stimulate
a non-specific innate immune response. Dendritic cells and macrophages
present foreign antigen to the adaptive immune system cells and thus
initiate a specific and directed response. In order to respond to a specific
pathogen, an individual must be able to recognize foreign cells as non-
self. Major and minor histocompatibility antigens and the ABO blood
group antigens are central to distinguishing one human from another
and therefore in recognizing self from non-self. Genetic polymorphism
describes genes encoded by varying alleles resulting in varied pheno-
types within a species. The blood group and major histocompatibility
complex (MHC) are polymorphic, with many different possible allelic
combinations leading to differences between individuals and allowing
an individual to recognize self from non-self. Rejection describes the
graft injury and loss of function due to the recipients non-acceptance
of the graft as self and the response which aims to remove it from the
body. Rejection can be classified into hyperacute, acute and chronic
phases. Both cell-mediated and antibody-mediated mechanisms lead to
allograft tissue destruction. By minimizing MHC mismatch and using
immunosuppression therapy, the immune response to a graft can be
reduced. This involves familial grafting when possible, matching donors
and recipients for similar human leucocyte antigen and identification of
preformed recipient antibodies.
Keywords Acute rejection; allograft; chronic rejection; hyperacute
rejection; isohaemagglutinins; major histocompatibility; polymorphism
Introduction
Autograft describes tissue transplanted from one part of the body
to another, such as skin and bone marrow. An isograft describes
tissue transplanted between genetically identical individuals.
Allograft describes tissue transplanted from another, non-
genetically identical, individual within the same species,
Nina Plant MBChB FRCA is a Specialty Registrar within the North Western
Deanery, currently training out of program as Clinical Fellow at The
Hospital for Sick Children in Toronto, Canada. Conflicts of interest: none.
Peter Wood BSc (Hons) PhD is Senior Lecturer in Immunology at the
Faculty of Life Sciences, University of Manchester, UK. Conflicts of
interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 13:6
Learning objectives
After reading this article, you should be able to describe:
C The molecular aspects of grafts that stimulate innate and
specific immune responses to transplants
C The immune mechanisms involved in different types of graft
rejection
C Measures used to prevent or minimise graft rejection
including kidney, liver and heart. A xenograft is tissue trans-
planted from another species.
The immune system recognizes an allograft as foreign and
therefore mounts a response, as it would to any foreign path-
ogen. After transplant of a graft, damage to both graft and
recipient tissues leads to activation of the non-specific innate
immune system as well as the specific adaptive immune system.
These responses must be prevented or depressed if the graft is to
survive and function.
Innate immune system
Mechanical trauma to the graft and transplant site as well as
graft-derived proinflammatory mediators (following peritrans-
plant ischaemia followed by reperfusion) stimulate a non-specific
innate immune response. Damaged cells express damage-
associated molecular patterns (DAMPs) which are recognized
through Toll-like receptors (Tlrs) and other receptors expressed
on cells of the innate immune system, leading to activation of the
immune cells. There is local vasodilatation and increased
vascular permeability with infiltration of neutrophils and
macrophages and activation of clotting and complement systems.
These cells secrete cytotoxic substances and phagocytose foreign
material. Dendritic cells are innate immune cells which are
important in presenting foreign antigen to the adaptive immune
system cells and thus initiating a specific immune response
against the grafted tissue.
Adaptive immunity
In order to respond to a specific pathogen, an individual must be
able to recognize foreign cells as non-self. Major histocompati-
bility complex (MHC) and minor histocompatibility antigens and
the ABO blood group antigens are central to distinguishing
individuals and therefore to recognizing self from non-self.
Although the innate immune system can be effective in elimi-
nating a potential pathogen, the specific adaptive immune
system allows a targeted approach. The adaptive system is also
able to remember potential pathogens in order to respond more
quickly and efficiently if re-exposed. Adaptive immune responses
are led by lymphocytes with cellular and antibody-mediated
components.
Recognition of the allograft
Genetic polymorphism describes genes encoded by various
alleles resulting in varied phenotypes within a species. It was
thought that most proteins, for example albumin, were
281 2012 Elsevier Ltd. All rights reserved.
 TRANSPLANTATION
genetically coded by non-polymorphic genes with uniformity
within a species. Polymorphic proteins, including the blood
group and MHC, have many different possible allelic combina-
tions leading to massive phenotypic variation within a pop-
ulation, and, importantly, to differences between individuals.
The elucidation of the human genome has made this picture
more complex. It seems that all proteins are produced by genes
with more or fewer alleles with greater consequent degrees of
variation of the end product. Polymorphism allows an individual
to recognize self from non-self. In an isograft the donor MHC is
identical to the recipients and the graft is accepted as self. The
likelihood of two non-identical individuals having an identical
MHC allelic make-up is very small and therefore allografts are
inevitably recognized as foreign. Even if matched at MHC, the
presence of different alleles at many genes creates multiple
differences between donor and recipient; where genes code for
proteins that can stimulate immune responses, the proteins are
known as minor histocompatibility antigens.
Blood group antigens
The ABO and Rhesus systems are two of many blood group
systems describing antigenic differences between individuals. In
the ABO system, there are four blood groups (A, B, AB, O)
depending on an individuals allelic make-up. Alleles A and B
code for enzymes producing specific erythrocyte cell membrane
carbohydrate antigens A and B. The blood group allele O is a null
allele. These alleles are inherited in a simple Mendelian pattern
with A and B alleles dominant. Both inherited alleles are
expressed antigenically on the erythrocyte.
All humans have antibodies, called isohaemagglutinins, to
those ABO blood group antigens that they do not express. In the
absence of prior exposure this is thought to occur because of
cross-reactivity between blood group and microbial and food
antigens. These antibodies result in severe transfusion reactions
if unmatched blood is transplanted, typifying a type-2 hyper-
sensitivity reaction (see Hyperacute Rejection below).
Major histocompatibility complex
The MHC is a gene complex encoding three classes of molecule.
In humans these molecules are also called human leucocyte
antigens (HLAs). MHC class III molecules include complement
and various cytokines. The primary function of MHC class I and
class II molecules is to present self and foreign peptides to T cells.
T cells recognize foreign peptides only when they are associated
with a MHC molecule; therefore, MHC molecules are critical in
the recognition of and consequent response to foreign material.
MHC class I molecules, expressed by all cells, indicate what is
occurring intracellularly by presenting peptides from the internal
cell environment. Conversely, MHC class II molecules present
peptides from the extracellular compartment and are expressed
only by antigen-presenting cells.
For antigen peptides to be presented, the antigens must be
processed intracellularly. The antigens are broken down by
proteolytic enzymes producing peptides of 8e15 amino-acids in
length. These peptides bind to MHC molecules and the MHC/
peptide complex is transported to the cell membrane and
expressed on the cell surface. Extracellular antigens must first be
endocytosed into the cell for this process to occur.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 13:6
The two main types of T cells are CD4 and CD8 T cells, which
recognize MHC class II- and I-associated antigen respectively.
Like antibody, T cells are antigen specific and recognize only one
antigen. Recognition of a foreign antigen occurs when the innate
immune antigen-presenting cells present antigen to CD4 T cells
in the lymph nodes and other lymphoid tissues. T cells specific to
that antigen bind to the MHCeantigen peptide complex via the
T-cell receptor. This stimulates the cells to differentiate into
T-helper cells. CD4 T cells can develop into different types of
helper T cells called Th1, Th2 and Th17 (Figure 1). They are
characterized by the production of different cytokines and
promote different type of immune responses. These include the
activation of B cells and CD8 T cells, which have also recognized
antigen. These cells differentiate into plasma cells and cytotoxic
T cells respectively, which then eliminate the recognized foreign
tissue (Figure 2). Th1 cells are thought to be the main promoters
of rejection responses, but recent data have shown that Th2 and
Th17 responses can contribute to graft rejection in different
circumstances.
CD4 T cells can also be induced to become Tregs, which are
regulatory T cells that can inhibit other cells of the immune
system (Figure 1). They have been shown to be able to inhibit
graft rejection experimentally and there is interest in whether
their manipulation can be used to improve clinical transplant
outcomes.
Minor histocompatibility complex
Minor transplantation antigens are probably involved in late
onset rejection because they are less effective stimuli to the
immune system. Over 80 have been identified, although there are
potentially thousands including non-ABO blood group antigens
and those associated with the sex chromosomes.
Rejection: response to the allograft
Rejection describes the graft injury and loss of function due to the
recipients non-acceptance of the graft as self and the response
which aims to remove it from the body. The recognition of an
allograft as foreign is almost inevitable. In addition, the response
to an allograft is highly exaggerated. For unknown reasons, allo-
MHC stimulates about 50-fold more T cells than conventional
environmental antigens. This is due to the complexities of
recognizing self and non-self. Direct recognition is when donor
MHC is recognized as foreign; this is thought to cause the
exaggerated T-cell response. Indirect recognition is the recogni-
tion of graft antigen presented by self MHC. Type 1 responses are
not thought to be important in graft rejection.
Cell-mediated responses
CD8 cytotoxic T cells: these have potent antigen-specific cyto-
toxic activity. They identify foreign cells to be killed by recog-
nition of the MHC/antigen peptide and attach to the cell with cell
surface adhesion molecules. They deposit perforins and release
proteases that puncture the target cell membrane and breakdown
intracellular proteins, initiating apoptosis.
Antibody-dependent cell-mediated cytotoxicity (ADCC): this
describes the process whereby antibodies identify the foreign
antigen and enable cell-mediated killing (see below).
282 2012 Elsevier Ltd. All rights reserved.
 TRANSPLANTATION

Differentiation of CD4 T cells

Cytokines Differential
Nave CD4 promoting cytokines Function in relation to
T cell differentiation Th secreted transplant rejection

IL2 Promotion of CD8 cytotoxic T cell

Th1 IFN production. Promotion of opsonizing
IL12 TNF and complement-fixing antibodies.
IFN Delayed type hypersensitivity.
IL4
IL5 Promotion of non-opsonizing
IL4 IL6 antibody.
IL13 Th2 IL9 Recruitment and activation of
IL10 eosinophils and basophils.
Thp IL6 IL13 Promotion of fibrosis.
TGF
IL17 Recruitment of neutrophils.
Th17 IL17F Activation of endothelial cells.
TGF IL22 Stimulation of fibroblasts.

Treg IL10 Inhibition of graft rejection

TNF

Nave CD4 T cells (Thp) differentiate into different types of helper T cells (Th) or regulatory T cells (Treg)
depending on the cytokines present. These secrete different cytokines and have different functions
in transplantation IFN, interferon; IL, interleukin; TGF, transforming growth factor; TNF, tumour necrosis
factor.

Figure 1

Delayed hypersensitivity: antigen-specific T-cell activation trig- Types of rejection

gers non-specific killing mechanisms. There is infiltration of the
graft tissue by neutrophils and macrophages as well as lympho-
cytes. These cells release nitric oxide, reactive oxygen species,
interleukin-1 (IL-1) and tumour necrosis factor-a (TNF-a), causing
an intense inflammatory response and tissue damage.
Antibody-mediated responses
B cells and T cells specific to the same antigen interact in the
specialized lymphoid system. T-cell cytokine release causes
a B-cell class switch to produce secretable antibody (immuno-
globulin (Ig)G, IgA and IgE). The antibodies retain antigen
specificity but with greater affinity. The B cells that have
switched class then differentiate into plasma cells, which secrete
those antibodies. Foreign cell damage by antibody is mainly due
to activation of the complement system and ADCC.
Complement activation: the complement system is a protease
cascade system with sequential activation. It is activated by
antibodyeantigen complexes and leads to the formation of the
complement process end product, the membrane attack
complex. This is able to lyse foreign cells. Complement proteins
also identify such material to phagocytes with receptors for
complement components and antibody.
ADCC: antibodies identify and coat target cells. Macrophages and
natural killer cells bind to the Fc region of the antibody, forming
an antigeneantibodyeimmune cell complex. The cells release
toxic substances onto the surface of the target cell, leading to cell
death.
Hyperacute rejection: as discussed above, when a recipient has
been serologically presensitized to an allograft, further exposure
results in rapid or hyperacute rejection. This occurs within
minutes to hours of transplantation. Sensitization may be to
previous transplant material, blood transfusions containing
donor leucocytes or, in parous women, to paternal HLA expressed
in fetal cells encountered at birth. As in ABO sensitization, this
can also occur despite no prior exposure because of cross-
reactivity to similar environmental antigens. This early recogni-
tion by donor-specific circulating antibodies, mainly of ABO
blood group and MHC-encoded antigen, leads to graft endothelial
damage. Subendothelial exposure activates the coagulation
system, leading to thrombosis and infarction and consequent loss
of graft tissue and function. Hyperacute rejection is rare in allo-
graft transplantation because routine screening of the recipient
before transplantation identifies antidonor antibodies.
Acute rejection: this occurs within weeks to months of trans-
plantation. There is graft infiltration by activated lymphocytes
and monocytes with tissue distortion and destruction and
vascular insufficiency. The immune mechanism is thought to be
a type-4 hypersensitivity reaction characterized by persisting
antigens and T-cell-mediated chronic inflammation. Pharmaco-
logical interventions used in transplantation modulate acute
rejection responses.
Chronic rejection: this describes the gradual loss of function
over months to years and is characterized by graft infiltration by

ANAESTHESIA AND INTENSIVE CARE MEDICINE 13:6 283 2012 Elsevier Ltd. All rights reserved.

Response to transplants
Graft antigens
T-helper cells
Macrophage
Cytotoxic
T cells
Antibody-
dependent
cell-mediated
cytotoxicity
Inflammatory cytokines
Graft
cells
Reproduced with permission from Wood PJ. Immunology of transplantation.
Anaesth Intensive Care Med 2006; 7: 6.
Figure 2
T cells with fibrosis and vascular insufficiency. The mechanism
is thought to be a delayed response (due to immunosuppression)
to mismatched minor transplantation antigens.
Graft-versus-host disease: most rejection reactions are due to
the recipients response to a donor graft, but the graft can mount
a response and reject the recipient tissues. This occurs most
commonly in bone marrow transplants because the graft
contains viable and active immune tissue and is transplanted into
an immunodeficient recipient. The donor T cells recognize mis-
matched recipient HLA alleles and release inflammatory cyto-
kines, resulting in acute and chronic rejection reactions. These
reactions can be prevented by immunosuppressive treatment or
by removal of donor T cells from the graft.
Prevention of graft rejection
By minimizing HLA mismatch the immune response to a
graft can be reduced. This involves familial grafting when
possible, matching donors and recipients for similar HLA
phenotypes, identification of preformed recipient antibodies and
immunosuppression.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 13:6
TRANSPLANTATION
Familial grafting
Each HLA gene set, or haplotype, is inherited as a whole with each
parent providing one haplotype. When a parent donates to his or
her child there is at least a 50% match of HLA alleles. Siblings
provide a one in four chance of a complete match. Owing to greater
HLA matching in familial grafting the minor transplant antigens
become more significant in the rejection process.
Tissue typing
The strength of an immune response relates to the number of
HLA mismatches between donor and recipient. To minimize this,
transplant donors and recipients are matched, providing recipi-
ents with transplant tissue with an HLA make-up as close as
possible to their own. It is possible to HLA type the majority of
B cell
alleles in order to match donors with recipients. This can be done
by adding specific cytotoxic antibodies to donors and recipients
blood samples. The antibodies bind to surface HLA peptides,
causing B-cell lysis by complement activation. The samples are
scored microscopically on the strength of reaction. Donors can
then be matched to recipients with similar phenotypes. More
Plasma cell
complex and automated modern techniques are based on the
same principle.
Cross-matching
Complement This identifies preformed antibodies to donor antigens. Recipient
fixation serum and donor lymphocytes are mixed and antibodies are
identified by lysis of donor cells or by staining and flow cytom-
etry. The presence of antibodies excludes transplantation of
blood and kidney grafts from that donor.
Inflammatory
mediators Immunosuppression
In most allografts there will be HLA mismatches as well as minor
antigen mismatches. Immunosuppression is, therefore, used to
reduce immune responses and graft rejection. Immunosuppres-
sants depress the acute rejection reactions but do not prevent
hyperacute or chronic rejection. Immunosuppressants reduce
lymphocyte proliferation and activation by blocking activation
signalling pathways. Steroids work by reducing lymphocyte
infiltration into graft tissue and inhibiting macrophage function,
particularly cytokine production.
Patients are initiated and maintained on baseline regimes,
often combination therapy, with additional treatment for acute
rejection episodes. The aim of combination therapy is to gain
sufficient immune depression with minimal adverse effects. A
FURTHER READING
Hale DA. Basic transplant immunology. Surg Clin North Am 2006; 86:
1103e25.
Van Buskirk AM, Pidwell DJ, Adams PW, Orosz CG. Transplantation
immunology. J Am Med Assoc 1997; 278.
Wood PJ. Immunological response to infection: inflammatory and adap-
tive immune responses. Anaesth Intensive Care Med 2006; 7: 181e3.
Wood PJ. Immunology of transplantation. Anaesth Intensive Care Med
2006; 7: 184.
Wood PJ. The immune system: recognition of infectious agents. Anaesth
Intensive Care Med 2006; 7: 179e80.
284 2012 Elsevier Ltd. All rights reserved.