TRANSPLANT

IMMUNOLOGY
Dr Rajarshi Datta
DM PDT NEPHROLOGY, IPGMER
 OUTLINE
• Definitions
• Transplant antigens
• Antigen presentation and recognition
• Mechanisms of transplant rejection
• Effectors of graft rejection
• Immunosuppressive drugs
 TERMINOLOGY
• Graft or Transplant: Transfer of living cells, tissues and organs
from one part of the body to another or from one individual to
another.
 different parts of the same individual (autografting)
 genetically similar individuals ie identical twins (isografting)
 genetically different organisms of the same species (allografting)
 different species
(xenografting)
• Principle function of immune system is to defend against infections

• Discriminate between self and non self

• Immune response to allograft is response to non self antigens

 TRANSPLANTATION ANTIGENS
Major Histocompatibility Complex (MHC):
• gene complex whose alleles encode polymorphic cell surface
glycoproteins involved in antigen recognition and presentation

• Located on chromosome 6p21.31.

• Comprises of more than 220 genes (3.6 Mb of DNA-0.1% of the

genome)

• MHC-matching between transplant donor and recipient greatly reduces

likelihood of rejection
ACTIVATION OF ALLOREACTIVE T-
CELLS
• T-CELL RECEPTOR ENGAGEMENT OF ANTIGEN (SIGNAL 1)
• T-CELL COSTIMULATION (SIGNAL 2)
• INTRACELLULAR SIGNALLING
• T-CELL CLONAL EXPANSION AND DIFFERENTIATION
• MEMORY CELLS
• EFFECTOR FUNCTIONS
ANTIGEN PRESENTATION AND
RECOGNITION
• Major Histocompatibility Complex (MHC)
• Class I HLA A, B, C bind to TCR on CD8 T-Cell
• Class II DR, DP, DQ bind to TCR on CD4 T-Cell
• Most polymorphic genes in human genome
• Co-dominantly expressed

• Direct presentation (Donor APC)

• Unprocessed allogeneic MHC

• Indirect presentation (Host APC)

• Processed peptide of allogeneic MHC
ANTIGEN PRESENTING CELLS
• Dendritic cells (most potent), macrophages, B lymphocytes, activated
human endothelial cells.
• Naiive Tcells are activated in secondary lymphoid organs, while
memory T lymphocytes can be activated by DCs throughout the body.
• Recent evidence suggests that donor DCs are extremely short lived
and transfer their cargo of donor HLA to recipient DCs(cross dressing)
• The presentation by cross dressed, recipient DCs of donor HLA to
directly alloreactive T lymphocytes is referred to as SEMI DIRECT
ALLORECOGNITION PATHWAY.
T CELL RECEPTOR COMPLEX
• TCR have chains α and β which form a heterodimer which recognizes
and binds to peptide-MHC ligand

• Each chain consists of a constant and variable regions

• The heterodimers are associated with a complex of 4 other signalling

chains, collectively called the CD3 (CD3εγ - CD3εδ)
 T CELL COSTIMULATION
• T CELL activation requires one signal through TCR complex and a
second, or costimulatory signal, through accessory molecules.

• In the absence of costimulation, there is T cell anergy, where they

become refractory to subsequent activation or even undergoes
apoptosis.

• Costimulation consists of both positive and negative signals to T Cells.

• INTEGRINS: LFA 1 and CD2 on T lymphocytes bind to ligands
ICAM-1/ICAM-2 and CD 58,respectively on DCs.

• B7-CD28

• CD40-CD154

• OTHERS-41BB,OX40,CD27,ICOS and their ligands

T CELL INTRACELLULAR SIGNALING
• Engagement of TCR induces phosphorylation of zeta chain as well as a
variety of adapter proteins which lead to activation of several
biochemical pathways (calcineurin, protein kinase C, MAP kinase)
T CELL CLONAL EXPANSION AND
DIFFERENTIATION BY
CYTOKINES(SIGNAL 3)
• Number of T Cells reacting to a given antigen is quite small, hence
clonal expansion and differentiation required

• Largely driven by cytokines , like IL-2

• CD 4 T cells, after prolonged stimulation, tend to express groups of

several cytokines depending on local environment, types of antigens
and type and activation status of APCs
• Th1 clones produce IL2,IL12,TNF,INF-Y,Lymphotoxin,etc

• Th2 clones produce IL4,IL5,IL9,IL10,IL13

• Th17 clones produce IL17,IL21,IL22

• T(follicular helper) lymphocytes: antibody production

• Earlier rejection was thought to be pure Th1 response, but it has been proved to be not true.

• T regulatory cells are important in maintaining self tolerance after removal of effector T cells.
EFFECTOR FUNCTIONS
 MEMORY T CELLS
• Most effector lymphocytes undergo activation induced cell death (AICD) by
apoptosis as the response progresses
• Few survive to give rise to MEMORY T CELLS
• Dependent on cytokines IL7 and IL15
• They retain antigen specificity and functional phenotype of their precursors and
consist of 2 major subsets: CENTRAL MEMORY AND EFFECTOR MEMORY
• Central memory T cells (express CCR7) circulate through both secondary lymphoid
and non lymphoid peripheral tissues and have large proliferative capacity
• Effector memory Tcells (express CXCR3) circulate predominantly through non
lymphoid tissues and spleen and have higher capacity for effector functions
through IFN-Y, perforin, granzyme.
MEMORY CELLS VS NAÏVE CELLS
• Longer lifespan
• Wider migration pattern
• Lower threshold for activation
• Recall response much stronger than primary response
• Only partially dependent on traditional costimulatory pathways
(therefore resisant to belatacept ,a CTLA4 Ig)
• Present in much higher frequency
HOW DO WE ACQUIRE ALLOREACTIVE
MEMORY CELLS
1. Cross reaction (vaccination/infection)

2. Blood transfusions, organ transplants, pregnancy

3. Recovery from lymphopenia( eg thymoglobulin used during

induction)
T LYMPHOCYTE MIGRATION
• Naiive lymphocytes circulate between blood and secondary lymphoid
organs where they get activated
• Specialized high endothelial venules and adhesion molecules(L-
selectin and LFA-1) and chemokine receptors(CCR7) are essential.
• Rolling- L-selectin and addressins on endothelial cells
• Adhesion and transendothelial migration- CCR-7,LFA-1 and
CCL21,ICAM-1/ICAM2 respectively
• After entering spleen, they encounter alloantigen bearing DCs and get
activated into memory and effector T cells
• Effector and memory T lymphocytes exit secondary lymphoid organs
(dependent on sphingosine 1 receptors S1P) And migrate to allograft
via blood stream.
• Express high levels of adhesion molecule VLA-4(binds to VCAM 1 on
inflamed endothelial cells) and chemokine receptor CXCR3.

• Role of CXCR3 controversial

B LYMPHOCYTES AND ANTIBODIES
• Naiive B cell activation is dependent on antigen recognition by BCR and on
critical help from T follicular helper cells inside secondary lymphoid organs

• BCR internalizes the antigen, it is then degraded to peptides and then

bound to MHC class 2 molecules and recycled to cell surface.

• These MHC 2 –peptide complexes are then recognized by CD4 T

cells,leading to stable contact between B lymphocyte and the T
lymphocyte providing help to it
• Since activated by same antigen- ‘cognate’ or linked interaction
• CCR7 on B lymphocytes and CXCR5 on T follicular helper cells are essential
for bringing together the two cells at the interface between B cell zones (or
follicles) and T cell zones inside secondary lymphoid organs.
• Help from T lymphocytes delivered in the form of co stimulatory ligand (CD
40L) and cytokines (IL4,IL5,IL6)
• Also receive stimulatory signals from myeloid cell derived cytokines such as
BAFF(BLys)
• B lymphocytes that receive all necessary stimulatory signals coalesce in
follicles to form germinal centres, where they proliferate
extensively,undergo affinity maturation and differentiate into plasma cells
and memory B lymphocytes
ANTIBODY STRUCTURE AND
FUNCTION
• Glycosylated protein molecules
• BCRs as well
• Four protein chains, two ‘heavy’ and two ‘light’ chains linked by disulphide bonds
• N terminus regions of heavy and light chains are variable regions, serve as antigen
binding site
• C terminus of heavy chains are non variable or constant, essential for effector functions
• Cause ABMR by two mechanisms: activating classical complement pathway; stimulate
macrophages and other immune cells by binding to Fc receptors that recognize the
constant regions
• IgM,IgG3,IgG1 and IgG2 activate complement while IgG1 and IgG3 also bind FcR to
stimulate macrophages and NK cells
Antibodies or immunoglobulins (Ig)
ANTIBODY INDEPENDENT FUNCTIONS
OF B LYMPHOCYTES
• Serve as APCs

• Function as bonafide cellular effectors that produce inflammatory

cytokines (eg TNF alpha)

• Subgroup known as Breg (regulatory B lymphocytes) characterized by

IL 10 secretion, modulate immune responses.
NATURAL KILLER CELLS
• Lymphoid cells that do not carry TCRs or BCRs but instead express complementary
activating and inhibitory receptors.
• Activating receptors recognize ligands induced on many cell types during
inflammation or infection, while inhibitory receptors bind self-MHC class 1 molecules.
• NK cells stimulated when balance is tilted in favour of activating receptors
• Allograft tissues express nonself MHC proteins, so they don’t engage inhibitory
receptors
• Hence NK cells respond to missing self,not to nonself as Bcells and T cells
• Can also be activated by Fc receptors
• Once activated, kill their targets by secreting same molecules utilized by CTL(perforin,
granzyme, INF gamma) and differentiate into memory cells
INNATE IMMUNE SYSTEM
• INFLAMMATORY CELLS (neutrophils, monocytes, macrophages,
dendritic cells)

• SOLUBLE MEDIATORS (complement system)

• Express non rearranging, germline coded receptors that recognize
braod nonself patterns present usually on microbes(LPS, viral
DNA/RNA) but also respond to molecules released by stressed or
dying cells (eg uric acid, nuclear proteins, ,DNA derived from
chromosomes or mitochondria)
3 PURPOSES OF INNATE IMMUNITY
• Mobilizes first line defense mechanisms like phagocytosis and release
of acute inflammatory mediators,ranging from small molecules to
cytokines

• Activation and maturation of APCs

• Participates in the effector phase of most adaptive immune responses,

providing foot soldiers that eliminate foreign antigens and cause tissue
damage or fibrosis in response to cytokines and antibodies produced by
lymphocytes
ISCHEMIA REFERFUSION INJURY
• Immediate inflammatory response to the process of depriving
harvested organs from blood supply, placing them on ice, and
reattaching them to the vasculature of recipient.
• Characterized by graft cell injury and death, activation of
complement, and infiltration of graft parenchyma with monocytes
and neutrophils.
• Reactive oxygen species released by hypoxic graft cells and infiltrating
immune cells are though to play an important role in the process.
TOLERANCE AND IMMUNE
REGULATION
• Tolerance broadly refers to the absence of immune responses to
specific antigens.

• During development, one of the critical functions of immune

system is to prevent responses directed toward self-antigens,
thus preventing autoimmune disease.

• achieved by central tolerance in the thymus and by peripheral

tolerance in extrathymic lymphoid tissue.
CENTRAL TOLERANCE
• During T-lymphocyte development, most T lymphocytes found in
the thymus have undesirable reactivities, and so are deleted or
made unresponsive by negative selection.
• T lymphocytes that recognize foreign antigen in the context of
self-MHC are positively selected and allowed to circulate in the
blood.
• The process of negative selection is imperfect, so autoreactive T
lymphocytes can be found in the periphery.
• Autoimmunity is usually prevented by the process of peripheral
tolerance.
PERIPHERAL TOLERANCE
• Peripheral tolerance is maintained by a number of mechanisms that include regulation by
specialized lymphocyte subsets known as TREG and BREG, anergy, and exhaustion.
• The mechanisms by which regulatory lymphocytes suppress immune responses are varied.
They include cytokines (e.g., IL-10 and TGFβ) and inhibitory membrane molecules (e.g., CTLA-
4). TREG in humans are CD4+ T lymphocytes that express high levels of CD25 and the
transcription factor Foxp3.
• Anergy and exhaustion refer to the state in which T or B lymphocytes become unresponsive
to re-stimulation with antigen.
• Anergy occurs when naïve lymphocytes encounter antigen in the absence of critical co-
stimulatory or help signals necessary for their full activation.
• Exhaustion occurs when effector or memory T lymphocytes repeatedly encounter a persistent
antigen, as would occur during chronic viral infection or in the case of an allograft.
• Repeated antigenic stimulation induces the expression of inhibitory molecules that keep T
cells hypo- or unresponsive. One example of such inhibitory molecules is PD-1.
• In the context of transplantation, tolerance can be defined as
the absence of a destructive immune response to a graft, in a
host with otherwise intact immunity.
• This generally implies that the patient is not on chronic
immunosuppression yet maintains excellent graft function.
• This is an important goal because transplant recipients are
otherwise subjected to global immunosuppression that leaves
them at increased risk for infections and malignancies.
• In addition, current chronic immunosuppression regimens do not
guarantee indefinite or even excellent long-term allograft survival
• A variety of experimental approaches have tried to take advantage of
basic mechanisms of tolerance in an attempt to induce
transplantation tolerance.
• The most promising strategy so far has been to induce donor-specific
tolerance by ablation or near ablation of the recipient‘s immune
system and reconstitution with donor hematopoietic stem cells (bone
marrow), thus generating either a transiently or permanently chimeric
immune system that does not reject donor organs.
• The mechanisms of tolerance in these patients appear to be a
combination of central (thymic) deletion of alloreactive T lymphocytes
and peripheral regulation.
THANK YOU