Mikai

Solid Organ Transplantation

by Dr. Roxas

• Organ transplantation has always been one of the dreams of physicians.

Indeed, what is more wonderful than to replace organs that function or not at
all, by new or healthy ones?
• Unfortunately, organ transplantation often leads to discussions in the media
that bring this part of modern medicine into discredit. This lecture has been
designed to inform the wider public about organ transplantation, retracing its
history and the extraordinary developments during the last three decades.
The perspectives for the coming millennium with the probable transition to
xenotransplantation (organ transplantation from another species into human)
will also be discussed.
• Organ transplantation cannot be compared with repairing a malfunctioning
organ. It’s not like putting your car in for a mechanical check-up!
• Hundreds of years B.C., Chinese physicians had already thought of organ
transplantation
• It is for sure not a coincidence that the two patron saints of medicine are
Cosmos and Damian…
• They performed the first transplantation by transplanting the leg of a Moor
into a Caucasian patient. These two <<surgeons>> received probably
celestial protection, explaining the success of their intervention
• The real history of transplantation starts at the beginning of the twentieth
century
• The research done in the laboratory of the Austrian surgeon ULLMANN
permitted renal transplantation in dogs and goats. The refinement of vascular
suture techniques, with the contribution of among other, the Noble Prize
winner CARREL, led to the application of renal transplantation in humans. The
surgical techniques were simplified and the ideal site of implantation for the
kidnet graft was defined.
• The Russina surgeon VORONOY performed the first human renal transplant in
1933. Several transplants were carried out during the forties and the early
fifties. KUSS, SERVELLE, DUBOST and HUME performed the first successful
ones in Paris in 1951
• Physicians came to understand that the transfer of tissue from one human
being to another provoked immunological reactions that destroy the
transplanted organ. There was no effective immunosuppression available at
this time. For this reason in 1954, long term survival after renal
transplantation was obtained only in identical twins.
• This was done by the team of Noble Prize winners MERRILL and MURRAY in
Boston
• From that point on, the evolution of organ transplantation was a constant
deviation from this ideal, but all too rare, situation. From the sixties onward,
organ transplantation between non-identical twins, then between family-
related donors and recipients and finally between unrelated donors and
recipients became successful.

Transplantation in the Philippines

• 1968  1st kidney transplantation from a cadaver donor at PGH by Dr. Enrique
Esquivel (Urologist)
• 1969  1st LRD-KRT at UST by Dr. Domingo Antonio
 • 1970  homecoming of Filipino transplant surgeons who trained under Starzle
(father of kidney transplant), Hamburger and Caine
• 1974  establishment of the Kidney Foundation of the Philippines
• 1970-1980s  15 to 24 KTs performed annually
• August 7, 1983  President Marcos underwent KT with son Bongbong as
donor (NKFP)
 Azathriopine and steroids
• September 7, 1984  President Marcos’ 2nd KT
 cyclosporine (Sandimmune)
• 1988  1st KIDNEY AND PANCREAS, 1st LIVER TRANSPLANT DONE AT NKI
 1st legal case concerning Organ Donation
• 1990 – 1st BONE MARROW TRANSPLANT DONE AT NKI
• September 18, 1990  1st KIDNEY LIVER TRANSPLANTATION DONE AT NKTI
• May 28, 1994  1st HEART TRANSPLANT DONE AT MAKATI MEDICAL CENTER
• April 12, 1996  1st SEGMENTAL LIVER TRANSPLANT FROM LRD DONE AT NKTI

TRANSPLANTATION
• the act of transferring an organ, tissue, or cell from one place to another
• the basic idea of transplantation is a simple one: to remove healthy organs,
tissues or cells (the graft) from one site (or individual) to another site (or
individual). Successful transplantation, however, faces many obstacles
including
o surgical techniques
o shortage of donors
o rejection by the host’s immune system
• Autograft
o Tissue transferred from one part of the body to another within the
same individual
• Isograft
o Tissue transferred between genetically identical individuals
• Allograft
o Tissue transferred between genetically different individuals of the
same species
• Xenograft
o Tissue transferred between indivudals of different species

IMMUNOLOGY
• once a basic understanding of transplant immunobiology has been achieved
towards the latter part of the century, obstaclesin rejection has been
overcome
• Success of current day transplantation is largely due to control of the rejection
process
• When a human kidney is accepted by a human recipient, you can immediately
see the blood flow in the kidney and that the color of the graft turns a
beautiful pink-auburn
• In the event of rejection however, the kidney will be progressively destroyed.
The defence mechanisms of the body trigger a series of immunological
processes, responsible for the formations of clots that will progressively
 obstruct the smaller and larger vessels, leading to the destruction of the
organ. The colour of the kidney will become dark purple. The transplanted
organ could be considered to be a large microbe.
• The body can not distinguish a <<good organ>> from billions of microbes. It
will launch a defense system that will, without preventative medication,
progressively destroy the transplanted organ.
• There are two sets of cell surface antigens that serve as the primary marker
for transplant survival:
o ABO major blood group glycolipids
o Major histocompatibility complex (MHC)
• Minor histocompatibility genes (mHC) are highly conserved in human species

Major Histocompatibility Complex

Anatomy of the Genetic Region

• MHC comprises 100 closely linked genetic regions occupying 2 centromorgans
on the short arm of chromosome 6
• The MHC genes encode cell surface proteins and human leukocyte antigens
(HLA)  self from non-self
• Class I region encodes the heavy polypeptide chain gene products of HLA A, B,
and C loci
• Class II region encodes both the alpha and beta chains of HLA DR, DP, DQ, DM
and DO molecule
o Also contains four genes that encode proteins that transport peptides
into the ER for loading into class I molecule (TAP 1 and TAP 2)

Structural Anatomy of Gene Products

• Class I products
o Every nucleated cells displays class I antigens on its cell surface
including both B and T lymphocytes
• Class II products
o Have limited distribution namely monocytes, macrophages and
activated T cells

Function of MHC’s
• MHC molecule serve as antigens in the artificial situation of transplantation
• Physiologic role is to present foreign peptides to lymphocytes bearing the
corresponding T cell receptor, thereby initiating the immune response of
clonal activation, proliferation and differentiation
• T cells may be grouped into subsets
• CD8+ (effector) T cells recognize antigens in association with Class I MHC
products
• CD4+ (inducer/amplifier) T cells recognize antigen in association with class II
MHC products

HLA nomenclature
• Nomenclature system is based either:
o Epitopes defined immunologically using either serological or cellular
techniques
o Biochemically by nucleotide sequence of allelic genes
• The former uses HLA followed by a hyphen represents the MHC; the capital
letters thereafter – A, B, C, DR, DP, or DQ – designate the segregant series
CLINICAL TISSUE TYPING

Inheritance of HLA antigens

• HLA genes display classic Mendelian inheritance  each individual inherits a
single chromosome (haplotype) from each parent and therefore has two HLA
haplotypes (one paternal and one maternal in origin)
• Haplotypes are usually inherited intact although in 2% recombinations
between HLA-A and HLA-DR occur during meiosis resulting in a new haplotype
• Since the expression of HLA A, B, and DR antigens is codominant, each person
displays a phenotype that includes two specificities for each locus (2 each for
HLA A, B and DR)

HLA TYPING PROCEDURES

Serologic detection of class I antigens

• standard procedure for serological identification of class I HLA-A, -B and –C
antigens is the complement-dependent microlymphocytotoxicity (CDC) test

Serologic detection of class II antigens

• Since class II molecules are only present on B cells, HLA-DR and –DQ antigens
may be identified by a microlymphocytotoxicity assay using purified B cells

Molecular Typing
• molecular typing procedures to identify HLA class II alleles HLA-DR, -DQ and –
DP are based on recognition of specific nucleotide sequence

IMPACT OF HLA MATCHING IN RENAL TRANSPLANTATION

Clinical Outcome
• among the living-related donor-recipient combinations, grafts from HLA-
identical siblings display the best survival followed by one haplotype matches
• Conflicting reports on the correlation between HLA matching and graft
survival
• 1.06 relative risk of graft loss for each HLA mismatch, increasing number of
HLA mismatches are associated with higher adjusted relative risks of failure of
first renal transplant
• Numerous individual and cooperative transplant center reports have failed to
observe a benefit of HLA-A, -B and –DR donor-recipient matching
• Disparity is attributed to differences in immunosuppressive protocols, patient
demographics, cross-match criteria, etc.
• Kidneys from living, genetically unrelated donors bearing full HLA mismatches
display outcomes superior to those of organs from cadaveric donors with the
same degree of mismatch

CROSSMATCH STRAGTEGIES

• Histocompatibility testing seeks to identify donor-recipient combinations likely

to yield successful transplants utilizing three principles:
o ABO blood group compatibility
o HLA matching
o Donor-specific crossmatching
 • Besides ABO compatibility, the pretransplant crossmatch is generally
regarded as representing the most important procedure performed in the
histocompatibility laboratory

Test Procedures
• Complement-dependent Cytotoxicity Assay
o Standard NIH-CDC
o Amos-modified CDC
o Antihuman globulin-enhanced CDC
• Binding Assay Techniques
o Flow cytometric
o Enzyme-linked immunosorbent assays
• Serum Screening Procedures

CLINICAL IMPLICATIONS OF CROSSMATCH TESTS

• When it was documented that a positive crossmatch predicted early graft

rejection, the standard microlymphotoxicity crossmatch was introduced into
routine renal transplant practice
• High risk for positive crossmatch
o Multiparous females
o Retrotransplants
o Recipients of blood transfusion
• The presence of antibodies that lysed T cells (a positive T cell crossmatch)
contraindicates transplantation, whereas B cell positive reactions were not
associated with graft failure in some reports
• The antihuman globulin (AHG) crossmatch enchanced the sensitivity of the
tests beyond that achieved with the standard CDC technique
o An AHG-positive result is an absolute exclusion of a recipient from
transplants from that donor
• Significance of a positive historical crossmatch when the result with the
current or pretransplant serum is negative
o Whereas a positive crossmatch result using a historical positive serum
represents a contrainidication for retrotransplantation, it does not
seem to have the same adverse prognostic significance for a candidate
for primary renal transplant
• Outcome of renal transplantation depends upon multiple factors:
o Immunosuppressive regimen
o HLA antigen matching
o Ethnicity
o Gender
o Degree of presensitization
o Transfusion history

CLINICAL REJECTION

• Graft rejection is a complex process involving several components, including T

lymphocytes, B lymphocytes, macrophages, and cytokines, with resultant
local inflammatory injury and graft damage
• Hyperacute rejection
• Accelerated rejection
• Acute rejection
• Chronic rejection
HYPERACUTE REJECTION
Time of Onset <48 hours
Response Secondary
Mechanism Preformed antibodies
Ab, platelet,
Histopathology granulocyte/depot
Therapy None
Success 0%

ACCELERATED REJECTION
Time of Onset 3-5 days
Response Secondary
Mechanism Preformed non-C+ binding Ab, cellular immunity
Histopathology Hemorrhage
Polyclonal antilymphocyte
Therapy globulin/plasmapheresis/cyclosphamide
Success 60%

ACUTE REJECTION
Time of Onset >6 days
Response Primary
Cellular Humoral
Mechanism Immunity Immunity
Lymphocyte
Histopathology infiltrate endovasculitis
Therapy Steroids/OKT3 Steroids/OKT3
Success 80-90% 60-85%

CHRONIC REJECTION
Time of Onset >60 days
Response Primary
Humoral antibody/nonantigen-dependent
Mechanism mechanism
Histopathology Vascular smooth muscle cell proliferation
Therapy None
Success 0%

CLINICAL IMMUNOSUPPRESSION

• The most aggressive immunosuppression is total body irradiation. This

method completely eliminates the bone marrow that is responsible for the
production of lymphocytes. Based upon knowledge gathered from irradiation
accidents in the former Yugoslavia, investigators introduced pre-transplant
irradiation therapy. Too many infections however, which were mostly lethal,
were the result of this method. More selective therapy was needed.
• In the early sixties, cortisone-based drugs (steroids) and cell-synthesis
inhibitors (azathioprine), contributed to the success obtained in renal
transplantation. The team STARZL made a fundamental discovery: rejection
was a reversible process
• Other drugs were developed. All had the aim to stop the attack of the
lymphocytes
 • The development of poly- and monoclonal antibodies (products produced in
horse, rabbit, rat and goat) was an important advance. Unfortunately the
quality and quantity of their production by the animals was uncertain.
• The solution came with the next discovery: hybridoma technology. Cells with
an infinite multiplication capacity (such as leukemia cells) were coupled to the
animal cells, in this way guaranteeing a more constant and more selective
antibody production
• Cyclosporine-based immunosuppression was introduced in the early eighties
• The drug is a kind of antibiotic that is produced by the spores found in
Norwegian fjords
• It has a cyclic form, hence the name cyclosporine. The immunosuppressive
qualities of the drug were clearly demonstrated by the Swiss scientist BOREL.
Its clinical introduction meant the start of several extra-renal transplantation
programs all over the world
• Other drugs were then developed and nowadays a multitude of efficient drugs
are available for clinical usage. A frequently used drug, Tacrolimus (FK506), is
produced by the spores discovered at Mount Fuji in Japan. Tacrolimus, like
Cyclosporine, is a cornerstone immunosuppressant. One of its benefits is the
possibility to reduce the amount of steroids used in combination, or to stop
them altogether. This is important, as steroids are often responsible for
physical and psychological problems in transplant patients. Other newer
adjunctive therapies available for clinical usage are mycophenolate mofetil,
rapamycin and chimerized or humanized antibodies (Basiliximab or
Daclizumab)

ORGAN PROCUREMENT AND PRESERVATION

• The biggest problem faced by transplant centers worldwide is the extreme

shortage of organ donors
• Different countries have varying advocacy campaigns to increase its organ
procurement

Types of Organ Donors

• Living Related Donors
• Living Non-related Donors
o Emotionally related donors
o Kidney Foundation of the Philippines
o Commercial donors
• Deceased Organ Donors

Living Organ Donors

• Surgeons commonly operate on a healthy individual
• Living donor transplantation possess a unique set of medical, ethical, financial
and psychosocial problems
• Living donors offer several advantages for the recipient