SOLID ORGAN TRANSPLANTATION

• 1st organ transplant (1954)

• Kidney, identical twin
• Dr. Joseph Murray
• Tissues and organs transplanted in human beings: BM, peripheral stem cells, bone
matrix, skin, kidneys, liver, cardiac valves, heart , pancreas, corneas & lungs

History
Transplantation

Two basic problems:

◼ Genetic variation between donor and recipient
◼ Recognition of genetic differences by a transplant patient’s immune system that causes
rejection of a transplanted organ
MHC
◼ Cluster of genes found in the short arm of
chromosome 6 at band 21
◼ MHC encode for HLAs which are the molecular
basis for T cell discrimination of self from non self
 • The MHC or HLA complex contains about
200 genes about 40 of which encode for
HLA. Majority of the antigens have no
role in immunity
• If the recipient's T cells recognize HLAs on
the surface of the (transplanted tissue)
graft as foreign, they will be targeted by
the T cells for elimination and rejection
MHC will occur (graft rejection by host)
• If immunocompetent cells on the donor
tissue target the foreign cells of recipient
for elimination graft versus host reaction
occurs (GVHD) occurs
 • Four major regions: D, B, C and A
• HLA Class I Region
Major • HLA-A, -B, -C regions
• Classic or Class Ia genes
Histocompatibility • Code for class I molecules
Complex Regions • HLA Class II Region
• HLA-D region
• Subdivided into three families, HLA-
DR, HLA-DC(DQ) and HLA-SB(DP)
• Codes for class II molecules
 CLASS I
Genetic Loci HLA-A, HLA-B and HLA-C
Heterodimeric
◼ Alpha chains (3) and beta-2
Chain Structure
microglobulin (encoded in Chr.
15)
Cell Distribution Most nucleated cells
Presents Antigen to Cytotoxic T lymphocytes (Tc)
Play a major role in GRAFT
Significance
REJECTION
CLASS II CLASS III
HLA-DR, HLA-DC(DQ) and HLA-
SB(DP)
Heterodimeric
◼ Alpha (2) and beta chains (2)
Gene products: C2, C4A,
B lymphocytes, macrophages,
C4B, Bf, TNF, Heat Shock
other antigen-presenting cells
Protein
(dendritic, langerhans),
activated T lymphocytes
Helper T lymphocytes (Th)
Antigen presentation and
interactions between
immunocompetent cells
 Transplantation Role
• MHC genes encode for cell surface antigens.
When the antigens were matched between donor
and recipient, the ability of a graft to survive is
more likely
• HLA antibodies causes transfusion reactions
despite proper crossmatching
Roles of MHC and • HLA antibodies are commonly found in the sera of
MULTIPAROUS WOMEN
HLA • If transplants are performed against MHC barriers,
graft will be rejected unless immunosuppressive
therapy are instituted
• Second only to ABO antibodies in influencing the
survival or rejection of transplanted organs
 Immunologic Role
• T cell can ONLY recognize antigens in the
context of MHC molecules (MHC
restricted!)
• Class I molecules regulate interactions
Roles of MHC and between cytolytic T cells (CD8) and target
cells
HLA • Class II molecules regulate interactions
between helper T cells (CD4) and APC
Differentiation of Individual
• Each individual possesses unique HLA
haplotypes
 Antigen present Related disease Risk
Ankylosing spondylitis 100x
HLA-B27
Reiter Syndrome 40x
Celiac Disease 9x
HLA-B8
Addison's Disease 6x
Roles of HLA-B5 Behcet's Disease 6x
MHC and HLA-DR2 Goodpasture syndrome 16x
HLA Gluten-sensitive
21x
HLA-DR3 enteropathy
12x
SLE
Pemphigus 32x
HLA-DR4
Rheumatoid arthritis 6x
 • HLA matching is essential in organ
transplantation and hematopoietic stem cell
transplantation:
• Organ transplantation
• Donor and recipient MUST be HLA-
typed before transplantation.
• The most important HLA antigens are
HLA-A, HLA-B, HLA-DR (everyone has
TWO copies of each allele)
• The best possible match is 6/6, worst
HLA Applications possible match is 0/6
• To prevent GVHD during bone marrow
transplantation, donor and recipient must
be HLA-identical
• HLA-matched platelets are indicated during
platelet refractoriness state
• Paternity testing
 Laboratory
Evaluation of
Potential
• HLA Typing
Transplant • Done by PCR followed by probing with sequence
Recipient and specific oligonucleotide probes (SSOPs)
• Recipient and donors must be HLA-typed and
Donors matched
• Screening of recipient’s serum for the presence of
alloantibodies
 Laboratory • Histocompatibility Testing
Evaluation of • Performed to rule out preexisting antibodies capable of
causing hyperacute rejection
Potential • Complement-Mediated cytotoxicity
• Uses a battery of reagent antisera (HLA antibodies),
Transplant isolated target cells and complements
• Binding of specific alloantibodies to corresponding HLA
Recipient and antigen, the complement will be fixed and cell will be
lysed
Donors • Cell death is determined via addition of vital dye (trypan
blue). Stain will penetrate the dead cells and will be
stained whereas living cells will remain brilliantly
refractile (unstained)
• T cells are preferred for Class I typing because they
express class I but NOT class II molecules
• B cells are preferred for Class II typing because they
express BOTH class I and class II molecules
Laboratory Evaluation of Potential
Transplant Recipient and Donors

◼ Solid-Phase Enzyme-Linked Immunosorbent Assay

◼ ELISA is available for panel-reactive antibody (PRA) determination and antibody-
specificity analysis
◼ ELISA-based HLA: reproducible, sensitive, and objective
 Laboratory
Evaluation of • Molecular Techniques
Potential • The first molecular method for HLA typing
was polymerase chain reaction (PCR)
Transplant amplification of DNA
• DNA-based HLA typing methods using
Recipient and molecular techniques include:
• Sequence specific oligonucleotide
Donors probe hybridization
• (SSO)
• Sequence-specifc primer amplifcation
(SSP)
• Sequencing-based typing (SBT)
• Reference strand–based conformation
analysis (RSCA)
 Laboratory
Evaluation of • Bead Technology

Potential • Use of the single-antigen bead assay to

detect antibodies to HLA loci such as DQA,
Transplant DPA, and DPB
• Not readily detected by other methods
Recipient and • Donor-Specific Antibody Tests
Donors • Anti-HLA antibodies specifically generated
against donor cells
• Presence of DSA in the 30% of renal
transplant recipients is associated with a
significantly lower graft survival
Solid Organ Transplantation

◼ Preferred treatment for end-stage organ failure due to improvements in the quality of life
and long-term cost benefits
◼ Demand is increasing by 15% per year
◼ The waiting time for allogeneic organ transplantation is dictated by numerous factors
Solid Organ Transplantation

Hematopoietic Stem Cells

◼ Currently being used to treat patients with many types of hematologic
disorders and malignant diseases
 • Blood type (some rare than others)
• Height and weight of transplant candidate
• Size of donated organ
• Medical urgency
Factors to • Time on the waiting list
Consider • Distance between donor’s hospital & potential donor
• Number of donors in local area over time
• Transplant center’s criteria from accepting organ offers
 • Autograft – Graft transferred from one position to
another in the SAME individual
• skin, hair, bone
• Syngraft/Isograft – Graft transplanted between
genetically identical recipient and donor
• kidney transplant between monozygous twins
Transplantation • Allograft (Homograft) – Graft between genetically
Terminology different recipient and donor of the same species; the
grafted donor tissue or organ contains antigens not
present in the recipient
• Xenograft (Heterograft) – Graft between individuals of
different species
• pig heart valve to a human heart
Types of Transplants
• 11 different organs or human body parts can be
transplanted
• blood vessels, bone, bone marrow or stem cells, cornea,
heart, kidney, liver, lung, middle ear, pancreas and spleen
• Successful organ transplants have increased since
the discovery of the immunosuppressive drug
cyclosporine (cyclosporin A)
 • Bone Marrow
• The donor is given general or regional anesthesia
• Marrow is usually aspirated with large needles from
SOURCES OF STEM the posterior iliac crest; the anterior crest can also
be used in certain cases
CELLS FOR
TRANSPLANTATION • Peripheral Blood Stem Cells
• Obtained for transplant by a procedure called
apheresis or leukapheresis
 • Umbilical Cord Blood
• At birth, cord blood is collected and put into a sterile
container, mixed with a preservative and frozen
• Successful alternative therapeutic option for
SOURCES OF STEM transplant patients who have no suitable related
allogeneic donors
CELLS FOR
• Engraftment
TRANSPLANTATION
• After the bone marrow or PBSCs are transplanted into
the recipient via a central catheter, the cells
migrate to the bone marrow, where they begin to
produce new blood cells
Graft vs. Host Disease (GVHD)
◼Etiology:
When immunocompetent T lymphocytes are
transfused from a donor to an immunodeficient
or immunocompromised recipient, the transfused
or grafted lymphocytes recognize that the
antigens of the host are foreign and react
immunologically against them
 Factor Comments
1. A source of Blood products, bone marrow
immunocompetent transplant, organ transplant
lymphocytes

Requirements 2. Human leukocyte antigen

differences between patient
The stronger the antigen
difference, the more severe the
for Potential and recipient reaction.

GVHD
3. Inability to reject donor Patients are severely
cells immunocompromised or
immunosupressed
Signs and Symptoms (Graft Rejection)
• Inflammatory response
• Post-transfusion/transplantation symptoms begin 3-30 days after transfusion
• Acute GVHD develops within the first three months of transplantation
• Lesions of the skin, liver and gastrointestinal tract, etc.
• Erythematous skin rash on the palms and soles are usually the first sign of GVHD
• Chronic GVHD resembles collagen vascular disease. Patients are susceptible to bacterial
infections
Signs and Symptoms (Graft Rejection)
• First-Set and Second-Set Rejections
• Skin transplantation is the most common experimental model for transplantation
research
• Hyperacute Rejection
• Caused entirely by the presence of preformed humoral antibodies in the host,
which react with donor tissue cellular antigens
• Accelerated Rejection
• Caused by activation of the T-cell–mediated response
Signs and Symptoms (Graft Rejection)
• Acute Rejection
• Results after the first exposure to alloantigens
• Donor antigens select reactive T-cell clones and initiate visible manifestation of
rejection within 6 to 14 days

• Chronic Rejection
• Occurs in most graft recipients
• Process results in a slow but continual loss of organ function over months or years
Diagnostic Evaluation
• Decreased total lymphocyte concentration
• High CRP
• Elevated leukocyte count with granulocytosis
• High ESR
• High levels of bilirubin and blood enzymes
• Presence of opportunistic pathogens (CMV)
• Lymphocytic and monocytic infiltration into the perivascular spaces in the dermis and
dermoepidermal junction of the skin. Infiltration also occurs in many areas of the body
Graft Rejection
• Organs vary with their susceptibility to rejection based on
• Inherent immunogenecity (high amounts of HLA antigens)
• Vascularity (contact with cells of immunity)
• Both cell-mediated and humoral-mediated immunity are involved in graft rejection
Graft Rejection
• Most immunogenic
• Bone marrow
• Skin
• Islets of Langerhans
• Heart
• Kidney
• Liver
• Bone
• Xenogeneic valve replacements
• Least immunogenic
• Cornea
 Time of Tissue Predominant
Type Cause
Damage Mechanism
Hyperacute Within minutes Humoral Preformed cytotoxic
antibodies to donor
antigens

Accelerated 2-5 days Cell Mediated Previous sensitization to

Categories of Acute 7-21 days Cell-Mediated

donor antigens

Development of

Graft allogeneic reaction to

donor antigens

Rejection Chronic Later than 3

months
Cell-Mediated Disturbance of host-graft
tolerance

Immunopathologic Later than 3 •Immune complex Immunopathologic

damage to the new months disorder mechanisms related to
organ •Complex circumstances
formation with necessitating
soluble antigens transplantation
 • Sensitization of the host by the so-called passengers lymphocytes in the
graft elicits graft rejection
• Only sites accessible to the immune system in the recipient are accessible
to graft rejection
• Host’s T cells recognize foreign class I and class II antigens. Binding of
lymphocytes to these foreign antigens leads to release of lymphokines and
activates nonspecific response.
• T cells specific for the class II antigens requires presentation of the donor
antigen before they are recognized.
• Antibodies destroy donor tissue via complement-mediated cytotoxicity or
they may function as opsonins to encourage phagocytic destruction of
host cells

Mechanism of
Rejection
• Maintenance immunosuppression: key to prevention of acute and chronic rejections
throughout the life of the graft
• Antirejection therapy: used in acute and chronic rejection therapy
• Three agents used to treat acute rejection are
• Steroids
• Antithymocyte globulin
• Muromonab-cd3

Therapy
• Most common form of therapy and includes
• Alkylating agents
• Purine and pyrimidine analogues
• Folic acid analogues
• Alkaloids
1. Azathioprine: inhibits purine nucleotide synthesis and metabolism and alters the f unction of RNA
2. Corticosteroids: Prevents monocytes from secreting IL-1
3. Cyclosporin A: Blocks T cell cytokine production by inhibiting calcineurin
4. Tacrolimus (FK-506): Mechanisms similar to cyclosporine but 50-100 times more powerful
5. Sirolimus (Rapamune): Blocks lymphocyte proliferation by inhibiting IL-2 signaling

Cytotoxic Drugs
5. Mycophenolate mofetil: Blocks lymphocyte proliferation by inhibiting guanine nucleotide
synthesis in lymphocytes.
6. Nulojix: A selective T cell costimulation blocker
7. Monoclonal antibodies
• Anti-CD3 monoclonal antibody: Causes T cell depletion by binding to CD3 receptor
• Dacliximab (Zepanax): Binds to the alpha unit of IL-2 receptor, thereby inhibiting T cell
proliferation.

Cytotoxic Drugs
 • Post–Organ Transplantation
▪ Five other major complications:
▪ Cancer
▪ Osteoporosis
▪ Diabetes
TRANSPLANTATION ▪ Hypertension
COMPLICATIONS ▪ Hypercholesterolemia

• Post–Stem Cell Transplantation

▪ Range from infection, GVHD,
rejection, and organ damage to
infertility and death
 • Xenotransplantation
▪ Transplantation, implantation, or
infusion into a human recipient of
TRANSPLANTATION either (a) live cells, tissues, or organs
from a nonhuman animal source or (b)
COMPLICATIONS human body fluids, cells, tissues, or
organs that have had ex vivo contact
with live nonhuman animal cells,
tissues, or
The end