Transplantation

UNIT 4: IMMUNOGENETICS AND TRANSPLANTATION

IMMUNOLOGY

Presented by
Santhiya K
II M.Sc biotechnology
18PBT014
• Transplantation: transfer of cells, tissues and organs from one
site of the body to another (in the same individual or between
two persons)
• Need?
• Cure for many diseases – replacing old, damaged or non-
functional organs with healthy, functional organs.
• Tissues, cells or organs- graft; transferred from donor (provides
the graft) to the recipient or host (receives graft).
• Transplantation immunology - sequence of events- after an
allograft or xenograft is removed from the donor and
transplanted into a recipient.
• A major limitation in the success of transplantation is the
immune response of the recipient to donor tissue.
 1944 : Medawar (Father of transplantation) showed that skin
allograft rejection is ahost versus graftresponse.
 1954 : The first successful identical twin transplant of a human
kidney was performed by Joseph E.Murray in Boston
 1967 : The first successful liver transplant wasdone by Dr. Thomas E.Starzl
 1967 : The first heart transplantation by Christian Barnard
 1968 : The first successful bone marrowtransplant was done by
E.Donnall Thomas
 Self tissue (Homograft) is transferred from one
region of the body to another
 Antigens of the autograft- similar to those seen in other
sites of the body.
 Immune system recognizes the self antigens of graft.
 No immune response -elicited
 Autograft survive a l l the life
 Ex., - Transfer of healthy skin to burned area,
- Use of healthy blood vessels to replace
blocked coronary arteries,
- Plastic surgery of skin.
 Also called syngraft
 Tissue is transferred between genetically
identical individualsof the same species
 Histocompatibility antigens of the
isograft and recipient – identical- graft
survives and not rejected.
 EX: human isograft can be performed
between Identicaltwins.
 Tissue is transferred between two genetically different
members of the same species
 Histocompatibility antigens of the allograft and
recipient or host - dissimilar - immune response is
elicited- leads to graft rejection
 Ex., In humans, graft is transferred fromone individual
to another
 Tissue is transferred between the individuals of two
different species; Also called as heterograft
 Ex., Graft of human transferred to animal
 Histocompatibility complex antigens between the
donor and recipient have genetic disparity - graft is
rejected more vigorously
 Types of graft
based on donor
 Types of graft based on transplant location

• Orthotopic – graft placed in their normal

anatomical location.
• Heterotopic – graft placed in a site which is different
from it’s normal anatomical location in the body; used
only when orthotopic placement may be technically
difficult.
1 . Control of infection
2 . Genetic matching of donors with host.

3 . Administering agents to inhibit the immune

system
4 . Lack of donors
5 . HLA typing and Tissue matching

6 . Immunosuppressive agents
 Immunological basis of graft rejection

• Degree of immune response varies with different types of graft.

• Autograft : used in burn patients and for replacement of blocked
coronary arteries with healthy blood vessels.
• Isograft: in monozygotic human twins and syngeneic mice
• Allograft: 2 kinds- first set rejection, second set rejection
• Xenograft: baboon heart to human; raising animals to serve as
organ donors for human is under serious consideration.
• Autograft and isograft : no rejection
• Allograft and xenograft: rapid rejection
 Allograft rejection displays memory and specificity

• Rate of allograft rejection depends on the tissue graft

involved.
• Skin grafts rejected more rapidly than other vital organ grafts.
• Allograft rejection : 2 kinds
• First set rejection: first exposure to the graft- complete
rejection within 12 to 14 days.
• Second set rejection: second exposure to the same allogeneic
graft- rapid rejection within 5 to 6 days- due to immunological
memory and specificity to the graft of previous encounter.
 Graft
rejected in
14 days
Strain B
Strain A graft
Graft B rejected
in 7 days
Graft C rejected
in 14 days

Strain C Strain B
Thus, allograft rejection meets two important
properties of immune system - Specificity and Memory.
 T cells play a key role in allograft rejection

• Transfer allogeneic immunity: mediated by T lymphocytes

through allograft rejection and not by serum antibodies.
• Experiments of proof:
1. Nude mice- lacks thymus and T cells in circulation- accepts both
xenograft and allograft.
2. 2 mice of inbred strains taken- strain A- allograft primed- first
set rejection occur.
3. Few days later- Strain B (naive strain) – same allograft primed- T
cells from strain A injected- directly second set rejection occur.
• Both CD4+ and CD8+ subpopulations of T cells cause rejection-
collaboration leads to more pronounced effects.
 Antigenic similarity for allograft acceptance
• Antigenic similarity between tissues – histocompatibility- no tissue
rejection.
• Histocompatibility determining antigens – encoded by 40 different
loci of the chromosomes.
• Proteins or antigenic molecules of MHC- encoded by Human
Leukocyte Antigen (HLA) gene complex- responsible for vigorous
allograft rejection reactions.
• MHC loci- closely linked – inherited as a complete set- in the form
of haplotype from each parent.
• In bred strain animals- homozygous MHC loci – donate and accept
grafts between them without evoking immune response.
• Out bred strains mating- F1 offspring receive one haplotype of MHC
from each parent- accept graft from either of the two parents but
can’t donate to both; any two offspring – 25% chance of having
identical MHC haplotype- suited for organ or bone marrow
transplants.
Graft donor and recipient are typed for RBC and
MHC antigens
• Different tissue typing procedures- identify the RBC and MHC
antigens- screen potential donor and recipient.
• Blood group antigens seen on the surface of RBC, endothelial
and epithelial cells- compared between donor cell and recipient
- if incompatible- antibody mediated complement lysis of the
donor cells can occur due to the ABO incompatibility.
• HLA typing- microcytotoxicity test – determines the presence or
absence of same MHC alleles in the donor and recipient.
• Mixed Lymphocyte Irradiation (MLR)- quantify the class II
MHC compatibility between the potential donor and
recipient.
• Indicates poor prognosis and graft survival due to increased TH
Cell activation.
• Disadvantage : require several days to run the assay.
• Match of class II MHC antigens between donor and recipient –
increases the chance of graft survival.
• Match or mismatch of class I MHC antigens- less effect on
graft survival
• All vital organ transplantation requires HLA matching.
 Cell mediated graft rejection occurs in two
stages
• Occurs during 7 - 10 days of the first set and 3- 4 days of second
set rejection- directed against the alloantigens (MHC antigens)
on the cells of graft.
• STAGE 1- SENSITIZATION PHASE: Alloantigen reactive T cell
subpopulation (CD4+ and CD8+) – activation and proliferation.
• Foreign Peptide of the graft- presented by either the allogeneic
antigen presenting cells (DIRECT or DOMINANT PATHWAY) or the
APC of host (INDIRECT PATHWAY) with high levels of class II MHC
molecules to the TH cells – co-stimulatory signals- recruit
different immune cells depending upon the tissue graft .
• Kidney, thymus, pancreatic islet grafts- passenger leukocytes- a
population of donor dendritic APC- migrate from donor graft to
regional lymph nodes and activate the T cells with allogeneic
MHC antigens.
 STAGE 2: EFFECTOR STAGE
• Cell mediated reactions- delayed type hypersensitivity and CTL
mediated cytotoxicity- most common than antibody mediated
reactions.
• Hall marks of graft rejection- influx of T cells (CTL) or
macrophages (DTH) into the graft.
• Recognition of class I alloantigens by host CD8+ populations- CTL
mediated killing.
• In some cases- CD4+ T cell population mediates class II MHC
restricted cytotoxic graft rejection.
• Cytokine secretion by TH cells- induce graft rejection- promote
high level expression of class I and class II MHC molecules on the
graft cells.
• IFN (α,β,Ƴ) and TNF (α,β): class I MHC expression
• IFN Ƴ : Class II MHC expression.
• Ex: rat cardiac allograft
 Clinical manifestation of graft rejection

• Immunological response or the clinical graft rejection occur by

three modes.
1. Hyperacute rejection: seen within first 24 hours- due to pre-
existing host serum antibodies that are specific for antigens
of the graft.
• Presence of pre-existing antibodies- repeated blood
transfusions, repeated pregnancies- Ab against paternal
alloantigens of the fetus, from previous graft.
• Xenotransplants- hyperacute rejection.
Hyperacute rejection
2. Acute rejection: after 10 days of transplantation-
involves infiltration of macrophages and lymphocytes-
mediated by TH cell activation and proliferation.
3. Chronic rejection: occurs months or years after acute
rejection reaction subsided- involves humoral and cell
mediated immunity- very severe- necessitates another
transplantation.
 Graft mounts an immunological response against the
Ag of host
 Graft contains the immunocompetent T cells
 Recipient possess the transplantation Ag’s that are
absent in the graft
 The recipient will not reject the graft but the
graft rejects the host
 Common in Bone Marrow Transplantation
 T cells from the transplant recognize the host MHC
molecules as non-self and attack the host.
This is a type IV hypersensitivity reaction
Antibody plays no role at all.
Occurs in
 Allograft- in a recipient in whom specific
immunological tolerance has been induced
 Adult lymphocytes injected into
immunologically deficient recipient
(Newborn).
 Avoided by – PURGING
 Removal of all T cells from the graft before
Transplantation by treating with Anti-CD3 Antibodies

Beneficial in – LEUKEMIA
 Moderate GvH reaction is beneficial to destroy the
residual leukemic cells which persists inspite of
chemotherapy
 In animal experiments – GVHD
 Runt’s disease
 Growth retardation
 Emaciation
 Diarrhea
 HSM
 Lymphoid atrophy
 Anemia
 Terminally fatal In
humans –
 Severe inflammatory reaction, Rashes,
Diarrhea & Pneumonitis
 Immunosuppressive therapy

• Survival of the graft- immunosuppressive therapy- 2 kinds-

general and specific.
• General immunosuppressive therapy- non specific- overall
immunosuppressive effect- increased risk of infection- slows
down the proliferation of activated lymphocytes and rapidly
dividing non immune cells.
 Mitotic inhibitors prevent T cell proliferation

• Azathioprine (Imuran) acts on S phase of the cell cycle- blocks

synthesis of inosinic acid- precursor of adenylic and guanylic
acid; administered before and after transplantation.
• Cyclophosphamide and methotrexate- used in conjugation;
acts on all rapidly dividing cells.
• Cyclophosphamide- alkylating agent; disrupts the DNA double
helix.
• Methotrexate- folic acid antagonist- block purine biosynthesis.
• Corticosteroids- prednisone and dexamethasone- anti-
inflammatory agents.
• Fungal metabolites as immunosuppressants- cyclosporin
(csA), FK506 (tacrolime), rapamycin.
• csA (acute nephrotoxicity), FK506: Block T cell activation by
inhibiting IL2 secretion.
• Rapamycin: block TH cell proliferation.
• FK506 and rapamycin: more potent than csA with few side
effects
• Total lymphoid irradiation: inactivates lymphocytes- X
irradiation given to thymus, spleen, lymph nodes- 200 rads
per day- several weeks up to 3400 rads.
 Specific immunosuppressive therapy

• Directed only against the alloantigens in graft.

• Monoclonal antibodies- bind to the surface of immune cells-
inactivates the specific immune subpopulation.
• Bind to CD3 of TCR complex – Ab coated mature T cells removed
from circulation using phagocytosis.
• Binds to high affinity IL-2 receptor in activated T cells- blocks the
proliferation .
• MAB against CD4 receptor- non depleting antibody -
immunosuppressed state of T cell- prolongs the graft survival.
• Donor BM treated with MAB- depletes immunocompetent T cells-
prevents graft- versus- host diseases.
• Origin of MAB: mouse- hence cleared from host circulation.
• Production of human MAB and mouse-human chimeric Ab-
overcome the disadvantage.
 Blocking co-stimulatory signals can induce
anergy
• Co-stimulatory signals are required for antigen activated T cell
population to proliferate against the grafted tissue.
• Blocked co-stimulatory signals – anergy of activated T cells.
• Examples of co-stimulatory signals:
• B7 molecule on APC with CD28 or CTLA-4 on T cells.
• CD40 on APC- CD40L on T cells.
 Clinical transplantation
• Kidney > liver > heart > lungs > pancreas > bone marrow.
• Kidney transplantation- most common; due to diabetes,
kidney failure; no Graft Versus Host Diseases (GVHD).
• Bone marrow transplantation- malignant and non-malignant
hematologic diseases- leukemia, lymphoma, aplastic anemia,
thalessemia major and immunodeficiency diseases like SCID.
• Prevention of GVHD: monoclonal anti T cell treatment to
donor bone marrow.
• Heart transplantation: once the heart is removed-
recipient sustained – with heart-lung circulating system.
• Donor heart- ice cold buffer solution.
• Transplanted heart- atherosclerosis- host Ab mediate injury to
the blood vessels of donated heart.
• 80% survival rate.
• Lung transplantation: cystic fibrosis, emphysema or any
acute lung damage; 60% survival rate.
• Liver transplantation: congenital defects, viral infection and
damage induced by chemical agents; 65% survival rate
• Pancreas transplantation: diabetes mellitus – produce
regulated levels of insulin- 55% survival rate.
• Skin graft: treats burn victim using autologous healthy graft or
allogeneic skin from a donor with immunosuppressive therapy.
• Foreign skin thawed from frozen deposits- used for biological
dressings – replaced regularly.
 Xenotransplantation
• Solution for shortage of organ donors.
• Major transplant donors: non-human primates- chimpanzee
and baboons.
• Disadvantages :
• Hyperacute rejection.
• Spread of pathogens from donor to the recipient.
• Ex: close relatives of HIV-1 virus, HIV-2, Herpes virus etc.
• Pathogen spread from non- primate donors to human- Less
possible.
THANK YOU!