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Introduction to Transplantation

Definition Law of Transplantation

Taking Cells, Tissues, Organs (called a graft) from one individual
Placing them into different individual (Allogeneic transplantation)
From one site to another in the same individual (Autologus transplantation)
Classification of Grafts (According to Source)
Graft from one animal to another, results in efficient Killing & Rejection
Grafts within same individual, there was No Rejection
Genetic Predisposition to Graft Rejection
Recognition of transplanted cells as Self/ Foreign is determined by
Polymorphic Genes inherited from both parents (e xpressed codominantly)
(eg. Individual expresses genes that are inherited from 2 parents)

MHC (Major Histocompatibility Complex)

Collection of genes in Chromosome 6 (s hort arm) in Humans
In Human, MHC = HLA complex (Human Le ukocyte Antigen)
Every individual express MHC proteins that appear foreign to another
individual’s immune system (exce pt Identical Twins)
MHC Structure

Terminology
Donor – provide Graft
Recipient/ Host – Receiver
Orthotopic Transplantation – Graft placed in normal anatomical location Class I Class II
Heterotopic Transplantation – Graft placed in different site HLA - A, B, C HLA – DR, DQ, DP, DM, DO
Can bind a peptide of 8-10 aa at Can bind a peptide of 10-30 aa at
Clinical Transplantation peptide binding cleft peptide binding cleft
Organ Transplanted Examples of Disease Expressed on All Nucleated cells Expressed on only
Kidney End stage renal failure • Dendritic cells
Heart Terminal cardiac failure • B lymphocytes
Lung or Heart/Lung Pulmonary HPT, Cystic fibrosis • Macrophages
Liver Cirrhosis, Cnacer, Biliary atresia Peptide antigens recognized by Peptide antigens recognized by
Cornea Keratitis CD8+T Lymphocytes CD4+T Lymphocytes
Pancreas Diabetes (Cytotoxic T Lymphocyte) (Helper T Lymphocyte)
Bone Marrow Immunodeficien cy, Leukaemia Role of MHC Proteins
Small Bowel Cancer Bind peptide antigens
Skin Burns Present peptide antigens at surface for inspection of TCR (T Cell Receptor)

Criteria before Transplantation Rejection in Transplantation

Occur becau se Immu ne System of recipient recognized & responds to
Damage is Irreversible/ Alternative treatments are not applicable
Foreign MHC antigens (alloantigens) expressed on graft
Disease must not recur
Same MHC molecules = Acceptance
(eg. Renal transplant – contraindicated in Goodpasture’s Syndrome)
(anti-glomerular basemenet membrane antibodies) Different Alleles = Rejection
Chances of Rejection ↓
Induction of Immune response against Transplants
Limitation of Transplantation Direct Allorecognition Indirect Allorecognition
Major Limitation – Immune response of recipient to Donor Tissue
Evidence – Transplanted skin undergo Necrosis & Fall off
Rejection – Inflammatory reaction
Rejection is caused by an Adaptive Immune Response

T cell recognized unprocessed Presentation of processed peptide of

allogeneic MHC on graft APC
T cells of host recognized intact MHC
expressed on the allograft’s APC
T-cell migration to transplanted
tissues
Transplated organ tissue is destroyed
(as a result of activation of CD8+T
cells by TH1 cells & Macrophages)
allogeneic MHC bound to self MHC
Allogeneic HLA Antigens are taken up
& processed by recipient APC
Peptides will be presented on host’s
MHC class II
CD4 T-cell allorecognition results if
donor & recipient MHC does not
match up
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Graft Rejection (Host vs Graft) Graft versus Host disease (GVHD)

Hyperacute Acute Chronic
Minutes → Hours Days → Weeks Months → Years
Preformed anti-don or 1° activation of T cells Unclear
antibodies and C’ Antibodies, Immune
complexe s, Slow
cellular reaction,
Recurrence of disease
Serum Antibodies react Macrophages, Correlated with release
to Foreign MHC Lymphocytes swarm of nonspe cific growth
(triggering complement the tissue factor like mediators
system) (eg. Fibroblast GF,
Endothelial GF)
Neutrophils inrush & Triggering Cytotoxicity Lead to insidious
Inflammation Complement activation Fibrosing & Proliferative GVHD induced by immunologically competent T cells (mature T cells) being
(cause Clot formation in Graft cell lysis reaction (vessel transplanted into allogeneic recipients whom are immunocompromised
blood vessels) occlusion ) Immunocompetant T cells transplanted with BM can attack the recipient
Graft dies without being TH activation time Is a major complication
vascularised 2 week delay Manifested by
At risks Most common type of Rash
Multiparous women allograft rejection Jaundice
Patients with previous Mediated mainly by T Diarrhoea
unsuccessful graft cells which react against Inflammation of Lungs, Liver, Kidneys
Xenograft is used alloantigens in graft Avoided by
Treatment Does not respond to ↑ Careful HLA typing
↑ dose of Immunosuppression Removal of mature T cells from graft
Immunosuppressive Immunosuppressive drugs
Risk of
Replace organ
Infection
Malignancy
Drug toxicity

Requirements for Transplant

Importance of a Close Match

↑ Degree of HLA Matching – Patient & Donor
Stem Cell Transplant (SCT)
↑ Patient survival
Restore Myeloid & Lymphoid cells in
↓ GVHD (Graft-Versus-Host Disease)
Haematological malignancy
Promote engraftment (donated cells regenerate new blood-formation cells)
(SCT proceeded by potent chemotherapy & irradiation to eradicate residual
Matching Donor & Recipient HLA alleles
tumour cells)
Tissue Typing (↓ GraŌ RejecƟon)
When Myeloid production ↓ or Abnormal (eg. Aplastic anemia)
1° Immunode ficiences Immunosuppressi on – Effective
HLA matching not considered necessary for many organ transplants
Recipients too sick to wait for closest match
Source of Stem Cells
Bone Marrow Peripheral Blood Stem Cord Blood
Cells Immunosuppressive Therapy
Non-Spe cific Specific
Require considerable Harvested after treating Immature lymphocytes
amount of don or donor with CSF (colony- are ↓ likely to cause Interfere with Immune Response Cyclosporine & FK-506
marrow under general stimulating factors) to GVHD Attenuates Rejection of Donor tissue Anti-CD3 mab
anesthetic ↑ circulating stem cells ↓ Immune responsiveness Anti-IL-2 receptor antibody
↑ Susceptibility to Pathogens, Cancers
CTLA-4-Ig
Anti-CD40 ligand
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Testing Donor-Recipient Compatibility

Each individual express
6 class I MHC alleles (HLA A,B,C from each parent)
6 class II MHC alleles (HLA DR, DQ, DP from each parent)
Matching Donor & Recipient HLA alleles by tissue typing - ↓ Rejection
ABO Blood Typing
Tissue Typing
Detection of Antigens on surface of Lymph ocytes
Serology DNA/ Molecular Technique s Cellular = Mixed Lymphocyte culture
Expose unknown cells to antisera of known HLA Restriction Fragment Length Polymorphism (RFLP)
specificity (Replaced by Polymerase Chain Reaction method )
Anti-HLA Antibody are ↑ specific that characterize Sequence Specific Primers (SSP)
the different antigen of HLA system
When Sera (containing HLA Antibody) are mixed Sequence Specific Oligonu cleotide Probe (SSOP)
with Lymphocytes, the Antibodies bind only to their • Analyze Allelic polymorphism at DNA level
specific antigens • Analyze Class II Micropolymorphism down to a
single a.a
Antigen-Antibody complex is formed on cell surface Sequence-Base d Typing (SBT)
Presents of Comple ment • Provide Highest resolution possible
Lead to cell Lysis/ Death • For discovering new allelels
• Potential impact on Transplantation
Cell Death = +ve test result Microarray technologies
(indicate shared specific of Antigen & Antibody)
(can identify antigens of the cell with +ve result)
Serological Methods SSP Principle
Cells examined under a phase contrast microscope • Based on PCR (enable enrichment of de fined
Cells that take up stain = +ve DNA sequences)
Healthy cells = Small, Round, Shine • Amplification occur only if Allele present
≥ 60% cells stained = +ve for HLA antigen • Each Well (contain oligonucleotide primers
Scoring Cytotoxicity by Cell Death compleme ntary to a small segment of only 1
Score Cell Death Interpretation HLA allele)
1-2 0-20% No HLA match • Sample Lacking the target for an allele-specific
4-6 20-50% Ambiguous result primer = Do not produce particular PCR
6-8 >50% +ve HLA match product

Crossmatching
Determine the presence of any preformed Antibody to Donor HLA Antigen
Lymphocytotoxicity method
Preformed by using Patient most recent Serum & Donor peripheral blood
Lymphocytes
+ve crossmatches = Contraindication to Transplantation (associated with early
& uncontrolled rejection episodes )(leading to Rejection)