Transplantation Immunology

Transplantation: Transfer of living cells/ tissues/ organs from one part of the body to
another or from one individual to another

Nomenclatures
 Host: recipient
 Graft: the tissue from the donor
 Autograft: from one part of the body to another (e.g. trunk to arm)
 Isograft: between genetically identical individuals (e.g. monozygotic twins)
 Allograft: between difficult members of the same species (i.e. most transplants)
 Xenograft: between members of different species (e.g. pig to human)

 Alloantigens: Antigen variation within species

 Alloreaction: Immune response to alloantigens

 Clinically relevant alloreactions in transplantation

- Host-versus-Graft (solid organ)
- Graft versus-Host (bone marrow)

 Diseased donor transplant

- Donation after brain death (DBD) (ventilator support at time of donation)
- Donation after circulatory or cardiac death (DCD) (ventilator support
withdrawn in OT  Additional warm ischaemic time)
- Extended criteria donor (ECD)
 Living donor transplant
- Kidney from living related or unrelated donor

Warm ischaemia time (WIT): time from extubation to organ removal and perfusion with
cold preservation solution
Cold ischaemia time (CIT): initiation of cold preservation solution to restoration of warm
circulation after organ implantation
History: First isograft kidney transplant in 1954 (the Herrick twins), first allograft in 1959,
first deceased donation in 1962

Modern kidney transplantation

- Organ transplant in Australia (832 kidney, 281 liver)
- Increasing trend in organ transplant recipients in Australia
- ESKD patients have dismal 5-year survival rates with >50% mortality rates in those aged
>65 years old
- ESKD patients have 10-40 times increased mortality compared to the age and gender-
matched general population
- ESKD patients have worse 5-year survival rates than majority of cancer
- Short term outcome: Primary living donor grafts have better survival outcomes (close to
100%) than primary deceased donor grafts (>90%)
- 1/ 5-year allograft and patient survival in Australia is better than that of US
- Long term outcome: in primary living and deceased donor grafts, both patient or graft
have a low survival rate and decreases over years post transplant (although better in living)
- Cardiovascular and cancer infection are the major factors affecting patient death with
function
- Acute rejection (first year 21%)) and chronic allograft nephropathy (beyond first year 75%)
are the major factors for graft failure
- Chronic allograft nephropathy (CAN) is now recognized to largely represent antibody-
mediated rejection (ABMR 50%)

Factors affection graft survival:

1. Donor/recipient quality (age/ comorbidities/ donation pathway)
2. Cold ischaemia time
3. Immunosuppression
4. Immunological (HLA-matching/ DSA)

Immunological barriers and transplantation

1. Blood group compatibility (ABO)
2. Human leukocyte antigen (HLA) matching
3. Donor specific antibodies (DSA)
a. Recipient antibodies direct at donor antigens
b. HLA/ non-HLA
HLA and basic immunology
- Specific group of proteins/ antigens located on leukocytes cell surface
- Responsible for recognition and stimulation of the immune response to self VS non-self
molecules
- Controlled by adjacent genes located on the short arm of chromosome 6 (major
histocompatibility complex [MHC])

HLA expression
- Co-dominant HLA gene expression: a protein from each parental gene is expressed on cell
surfaces
- New haplotypes can be formed through recombination of parental haplotypes

HLA characteristics
- HLA are highly polygenic and polymorphic
- Large number of possible variations/ combinations (permutations) of HLA means that
family members are more likely to be HLA-matched compared to individuals from the
general public
- HLA distributions vary according to specific population
 Isolated tribes often have a restricted number of alleles
 Large numbers of alleles in large African populations

HLA polymorphisms: Over 99% of our gene are the same, our HLA type accounts for much of
the difference

HLA Class I
- HLA-A
- HLA-B
- HLA-Cw
HLA Class II
- HLA-DR
- HLA-DQ
- HLA-DP
Innate immunity
 Non-specific defense mechanism against foreign antigen (immediate response)
 Recognises broad range of pathogen associated molecular patterns (PAMP)
 Crucial role of processing foreign antigens and initiation of adaptive immunity
 Main components
o Epithelium (skin/mucosal membranes)
o Antigen presenting cells (dendritic cells)
o Natural killer cells)
 Complement

Adaptive immunity
 Acquired immune mechanism targeted against specific foreign antigen/ molecules
 Enhances/ completes initial innate immune responses
 Crucial for immune ‘memory’ responses against antigen re-exposures
 Main components
o Cellular (T-lymphocytes)
o Humoral (B-lymphocytes/ antibodies)

Antigen presenting cells

 “Professional” (Macrophages/ DC/ B-cells)
o Phagocytes
o Receptors for DAMP/ PAMP/ apoptotic cells
o Constitutively express MHC class II
o Express co-stimulation molecules during activation
  “Atypical” (basophils/ eosinophils/ mast)
o Inducible expression of MHC class II
o Limited APC function to specific environment (type II immune reactions)
o Ability to activate naïve T-cells (?)

Cellular immunity (T-cells)

 Activated by interaction with APCs
o Antigen-MHC class II complex
o T-cell receptor (TCR)/ CD3
o Known as signal 1
 TCR-MHC signaling is essential but is not sufficient on its own for T-cell activation
o Clonal/ antigen-specific energy
 Antigen independent co-stimulation is required for full T-cell activation
o CD80/86-CD28
o CD40-CD154 (CD40L)
o Known as signal 2
T-cell Allorecognition pathways

Humoural immunity (B-cells)

 Antigen receptors are surface bound immunoglobulin
 Activated by effector helper T-cells/cytokines
 Clonal expansion after activation
o Memory B cells
 o Immunoglobulin secreting plasma cells
 Circulating immunoglobulin/antibody
o Complement system activation
o Membrane attack complex (MAC) o
o Opsonisation (marks pathogens for phagocytosis)

HLA-matching and transplant outcomes

  Histocompatibility (tissue typing) determines recipient ability to accept donor organ
 Single foreign HLA-antigen stimulates 1- 10% circulating T-cells (compared to 1 x 105
by microbial pathogens)
 HLA-matching is one of the most important predictors of transplant outcomes
(traditionally)

HLA-matching and transplant outcomes

 All HLA-loci mismatches are associated with poorer graft outcomes
o DR > A/B
 HLA tissue typing is essential for placement on the deceased donor transplant wait-
list
 Relative importance slightly diminished by current era of immunosuppression

Donor Specific antibodies (DSA)

 HLA antibodies can develop after exposure to foreign HLA antigen
o Pregnancy (foetus & paternal HLA)
o Blood-product transfusion
o Previous transplant
o Cross-reaction with viral exposures/vaccinations
 Antibodies against donor HLA are donor specific antibodies (DSA)
o Hyperacute rejection (high-titres)
o Inferior short/long-term graft outcomes (low-moderate titres)
 Highly sensitised recipients have multiple HLA-antibodies & are likely to have pre-
formed DSA

Pre-transplant DSA: increased risk of antibody-mediated rejection (AMR)

 Those with HLA-DSA has higher probability of AMR
 Those with both HLA-DSA and AMR has lower death-censored allograft survival rate
than HLA-DSA alone

Pre-transplant DSA & long-term graft outcomes

 Pre-transplant DSA are associated with reduced graft survival even in the absence of
AMR
 Both pre-transplant class I/II DSA are associated with inferior graft outcomes

Post-transplant DSA: Clinical relevance

 Development of post- transplant (de novo) DSAs are associated with worst graft
prognosis than pre-transplant DSA

HLA-matching: real world example

 Checking for the mismatches of HLA-A, HLA-B, HLA-DR then calculate the total HLA-
mismatch

Rejection and kidney transplant

 Hyperacute rejection (solved)
 Acute rejection (uncommon <15-20%)
 o Cellular
o Humoural
 Chronic rejection (remains a BIG problem

Hyperacute rejection
 Occurs immediately after graft revascularisation (minutes)
 Caused by presence of high titres pre-formed DSA/ABOi
 Antibody deposition upon graft endothelial cells
o Complement activation
o Fibrinoid necrosis
o Thrombosis

Acute cellular rejection

 Mediated by effector T-cells reactive to graft parenchymal (tubulointerstitium) or
endothelial cells
 Often asymptomatic & manifests as rising serum creatinine (current
immunosuppression era)
 Treatment:
o IV methylprednisolone
o Anti-thymocyte globulin (ATG)

Acute humoural rejection

 Mediated by complement-fixing antibody binding to donor antigens displayed by

peritubular & glomerular capillaries
 C4d is a complement component which binds to renal tissue after complement
activation & represents recent attack by complement-fixing antibodies
 Treatment:
 o Remove circulating antibody
 Plasma exchange (PLEX)
o Suppress antibody production
 IV immunoglobulin (IVIg)
 Rituximab (anti-CD20 monoclonal antibody)
 Splenectomy (rare)

Chronic rejection
 Chronic allograft rejection (T-cells)
o Transplant arteriosclerosis/vasculopathy
o Chronic allograft nephropathy (CAN)
o Chronic interstitial fibrosis/tubular atrophy (IFTA)
o Inflammation in IFTA area (i-IFTA)
 Chronic antibody-mediated rejection
o Transplant glomerulopathy (often DSA/C4d positive)

T-cell signalling pathways

Cyclosporine
 Fungal polypeptide (11 amino acids)
 Binds to intracellular cyclophilin protein receptors (immunophilins)
 Inhibits calcineurin which is a phosphatase necessary for dephosphorylation of
Nuclear Factor of Activated T-cells (NFAT)
 NFAT plays a crucial role in IL-2 production
 Suppresses cell-mediated immunity (decreased T-cell activation/proliferation)

Tacrolimus (FK506)
 Fungal macrolide antibiotic
 Chemically unrelated to cyclosporine but similar action
 Binds to another immunophilin known as FK-binding protein (FK-BP)
 Tacrolimus-FKBP complex inhibits calcineurin

CNI monitoring
 Cyclosporine (twice daily dosing)
o Trough levels (pre-dose; C0)
o AUC studies
 Peak CNI inhibition within 4hrs
 High individual pharmacokinetic variability
 Poor correlation with C0 levels
  2-hrs post dose levels (C2)

Tacrolimus (twice daily dosing)

 Trough levels (T0)

CNI nephrotoxicity
 Acute effects
o Glomerular arteriolar vasoconstriction (?endothelin)
o Type IV renal tubular acidosis (RTA)
 Chronic effects
o Arterial ischaemia/tubular injury
o “Striped fibrosis”
 Haemolytic uraemic syndrome (HUS)

Mycophenolate mofetil
 Semisynthetic derivative of mycophenolic acid (MPA) from fungi
 Prodrug which is metabolised to MPA
 Inhibits purine synthesis de novo
o MPA blocks inosine monophosphate dehydrogenase (IMP)
o Deprives nucleic acid supply for proliferating T- and B-cells
Molecular target of Paramycin (mTOR) inhibitors
 Fungal macrolide antibiotics
 Inhibit signal transduction & DNA/protein synthesis
 Cell cycle arrest (G1)
 Can be used as alternative to CNI or substitute for anti-metabolite

Belatacept (CTLA-4-lg)
 2nd generation human fusion protein
o Fc fragment of IgG1
o Extracellular domain of cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4)
 CTLA4 is a T-cell surface receptor which binds with CD80/86 (competes with CD28)
o CTLA4-CD80/86 binding results in inhibitory signalling
 CTLA-4-Ig therefore selectively blocks the co-stimulation pathway (signal 2)
Future: immune tolerance?
 “Holy grail” of organ transplantation
o Absent specific immune response to donor antigens
o Intact immune response to other immune stimuli
 Regulatory T-cells (Treg)
o Success only in vitro or in vivo
 Bone marrow ablation-stem cell transplantion?

Summary
 Renal transplantation is the optimal treatment for ESKD
 Immunological barriers to renal transplant
o ABO-incompatibility
o HLA histocompatility
o DSA
 Rejection remains a leading cause of long-term graft loss
Assessment, Detection and Management of Alcohol Use Problems-1

Two primary reasons:

- Pleasurable sensation
Reward pathway
- There is an axonal network in the brain labelled the ‘reward pathway’
- This reward pathway is activated by food, water, sex, exercise and some activities
- also activated by drugs and alcohol
- Relief of discomfort (psychological or physical)

Secondary reasons (because it is accepted or not accepted) (a feel of rebellion)

Reward pathway
- There is an axonal network in the brain labelled the ‘reward pathway’
- This reward pathway is activated by food, water, sex, exercise and some activities
- also activated by drugs and alcohol

Determinants of alcohol use problems

- Biological:
- Genetic predisposition to dependency
- Acetaldehyde dehydrogenase deficiency
- Psychological
- but beware direction of causality (anxiety - driving force of alcohol)
- Social
- environment, peers, culture, price, availability, legal status
- western: taught from a young age, north VS south Europe, aboriginal, Islamic +-
sharia law, Jewish

Role of industry
- Powerful body
- Multi-billion dollar interest
- Several large companies
- Active campaigns against the interest of public health
- Perception VS reality
Hepatitis viruses

Liver functions:
¢ Secretory, immunological, excretory, regulatory functions:
¢ Regulates metabolism
¢ Carbohydrates, amino acids and lipids
¢ Detoxifies body (alcohol, drugs, poisons, waste etc.)
¢ Stores vitamins (A, D, K and B12)
¢ Produces proteins, hormones and cholesterol
¢ Haematological regulation
¢ Phagocytosis and antigen presentation
¢ Removes circulating hormones, antibodies and toxins from the blood
 Produces bile and urea

What causes hepatitis

¢ Drugs / medicines
¢ Alcohol
¢ Autoimmune disorders (e.g. AIH)
¢ Inherited diseases (e.g. Wilson’s disease) ¢ Obesity, diet and lifestyle
¢ Malignancy
¢ Poisons / chemical exposure
¢ Vast majority is caused by viruses:
¢ Most commonly hepatitis A, B and C viruses
¢ Also hepatitis E virus, Delta virus, EBV, HCMV, HSV, HHV6, mumps, rubella and
yellow fever virus

Definitions
¢ Hepatitis: (hepato: liver, itis: inflammation)
¢ Acute: Short term and/or severe
Typical presentation: malaise, anorexia, vomiting, right upper quadrant pain
¢ Chronic: Lasts >6 months, often severe (liver function test abnormalities without
cirrhosis)
¢ Cirrhosis: Scarring from infection, toxins etc.
¢ Fulminant: Develops quickly, high mortality rate
¢ Jaundice: Yellowing of the skin / eyes
 due to raised levels of bilirubin in the blood from liver damage