Imunitate de transplant

Transplant
Definitii
Autogrefa: transfer de tesuturi de la la
acelasi organism (piele)
Allogrefa: transplant intre indivizi diferiti ai
aceleiasi specii
Isogrefa (singenic): transplant intre gemeni
identici (univitelini)
Xenogrefa: transplant de la o specie la alta
 Compatibilitate de Transplant
Pentru a creste sansa de supravietuire a
transplantului:
Cel mai important: compatibilitate ABO
Absenta Ac citotoxici preformati impotriva
Ag HLA ale donatorului
Compatibilitate HLA, in particular pentru
locii D
 VIROLOGICAL ASSESSMENT

Both donor and recipient are tested for: HBV, HDV, HCV,
HIV 1/2, CMV, EBV, HSV 1 and 2, VZV, HTLV 1/2 ,
rubella virus, toxoplasma gondii and chlamydia.

Methods
Indirect diagnostic tests (serological) - Antibodies
Direct diagnostic tests, molecular biology tests (PCR, RT-
PCR) DNA- RNA-virus
HLA
 IMMUNOGENETICS
1. Cross- match
- CDC
- ELISA

2. HLA Typing by molecular biology methods PCR

SSOP- sequence-specific oligonucleotide probe hybridization

(medium resolution )
SSP sequence-specific primers (high resolution)
SBT Sequence Based Typing allele SEQR (the highest available
resolution)

3. Anti-HLA antibody detection and identification

- AHG CDC
- ELISA
 Major Histocompatibility Complex

Lymphocyte crossmatch
Used to screen recipient serum for anti-HLA
antibodies
Recipients serum, complement and donor B
lymphocytes are mixed together in a test tube. Lysis
of donor lymphocytes is indicative of cytotoxic
antibodies in the recipients serum directed against
donor lymphocytes
The identity of these antibodies must then be
determined in order to find a suitable donor who is
negative for the corresponding HLA antigen(s).
Sample of cells or tissue

Combine DNA with sequence-

specific primer fix for each
allele

Amplify by
PCR
DNA
80ng for Class I
40 ng for Class II
 Importance of DNA Quality

100 ng Genomic DNA 1% Agarose Gel

Assign-SBT Resolves Ambiguities
Sequences are arranged in layers
Master sequence
 Types of Transplants
Corneal
Best graft survival rate since the cornea is
avascular and the lymphatic drainage from the
eye is not as well developed as in other tissues
Associated with transmission of prions-
Creukfeld-Jacob disease-Transmissible
spongiform encephalopathy; also has been
associated with amoebic transmission
(granulomatous amebic encephalitis)
 Types of Transplants
Renal
Between living donors with a 2 haplotype match = 90-
95%, 5 year survival
With a 1 haplotype match = 80%, 5 year survival
Cadaver transplants between unrelated donors is the
most common type of transplantation. Similar statistics
to 1 haplotype match when the recipient receives
multiple blood transfusions prior to the surgery
(induces tolerance to the allograft) and is placed on
immunosuppressive therapy
 Types of Transplants
Liver
In adults with chronic active hepatitis or
cirrhosis
In children with biliary atresia
1 year survival rate is slightly greater than 90%
 Types of Transplants
Cardiac transplantation
In adults, used in patients with chronic ischemic
heart disease and congestive cardiomyopathy
In children, endocardial fibroelastosis is the
usual indication
Endomyocardial biopsies are the best means of
diagnosing allograft rejection
Approximately 80% of transplants survive 1
year
 Types of Transplants
Bone marrow transplants
Used in the treatment of aplastic anemia,
leukemia and immunodeficiencies
Goal is to infuse donor marrow containing
pluripotential hematopoietic stem cells that will
eventually repopulate the lymphoid, erythroid,
myeloid, and megakaryocytic series in the
recipient.
GVH occurs in almost 2/3rds of cases
Increased incidence of CMV pneumonitis
 Transplant Rejection

The chance of a sibling in a family having another

sibling with 0, 1, or 2 haplotype match is:
25% - 0 haplotype match
25% - 2 haplotype match
50% - 1 haplotype match
However, a 2 haplotype match is rarely
achieved due to crossovers between the
individual loci during meiosis when
homologous chromosomes line up close to each
other
 Transplant Rejection
Three types of transplant rejections
Hyperacute rejection
Acute rejection
Chronic rejection
 Transplant Rejection
Hyperacute rejection:
occurs within minutes of attaching the allograft to the
recipients blood supply
Due to the presence of an ABO mismatch or preformed
cytotoxic antibodies in the host against foreign HLA
antigens in the donor tissue (example; a blood group A
recipient would have anti-B IgM antibodies and would
react against a group B donor heart)
Hyperacute rejection is rare because ABO and
anti-HLA cytotoxic antibody screening is
performed prior to the surgery
 Transplant Rejection

Acute rejection
Most common type of rejection encountered
Usually occurs within the first 3 months of the
transplantation
Involves cell-mediated and antibody-mediated reactions:
Cell-mediated has the greatest role in rejection
The type II antibody-mediated hypersensitivity produces
a necrotizing vasculitis with subsequent vessel damage
and intravascular thrombosis
 Transplant Rejection
Acute rejection
Vessel events can occur over a period of time
leading to fibrosis and vessel lumen obliteration
The cell-mediated component involves
cytotoxic T cells producing extensive interstitial
infiltrate in the graft with edema and damage to
the tissue (Type IV hypersensitivity)
Can be reversible with immunosuppressive
drugs such as cyclosporin A, corticosteroids,
and OKT3.
 Transplant Rejection

Chronic rejection
Irreversible
Occur over a period of months to years
Extensive fibrosis and loss of organ structure
characterize the histologic findings in the transplant
Activated macrophages release growth factors that
stimulate fibroblasts to deposit collagen
There is also chronic ischemia secondary to antibody-
mediated damage to the vessels
 Transplant Rejection
Cyclosporin A inhibits CD4 helper T cell release
of interleukin-2 (blocks calcineurin) which
stimulates the proliferation of cytotoxic and helper
T cells
Corticosteroids inhibit macrophage production of
interleukin-1 and tumor necrosis factor and are
cytotoxic to immature cortical derived thymocytes
OKT3 is a monoclonal antibody preparation that
attaches to the CD3 antigen receptor of T cells,
blocking their reaction with the graft
ID/CC A 45 year old male with refractory acute myeloid
leukemia is brought to the emergency room with fever, a
generalized rash, jaundice, right upper quadrant pain,
severe diarrhea, and dyspnea; two months ago, he
underwent an apparently uncomplicated bone marrow
transplantation.
HPI Prior to the transplant, he received radiotherapy and
chemotherapy as well as broad-spectrum antibiotics
PE VS: normal blood pressure. PE: cachexia; moderate
dehydration; 2+ jaundice; violaceous and erythematous
macules as well as papules and bullae with scale
formation over extremities
Labs Elevated IgE level. CBC/PBS: falling blood counts;
relative eosinophilia. Elevated direct serum bilirubin
and transaminases, no infectious agents on stool
exam
 Graft versus Host Reactions

Potential complication in bone marrow and liver

transplants and in blood transfusions administered to
patients with T cell immunodeficiency
Donor lymphocytes produce interleukin-2
-->activation of NK cells (primary effector cells in acute
GVH reactions)-->lymphokine-activated NK cells are
called LAKs and produce extensive epithelial cell
necrosis in the biliary tract (jaundice), skin
(maculopapular rash), and GI tract (diarrhea)
 Graft versus Host Reactions
May progress into chronic GVH which is
marked by the presence of extensive
fibrosis
To lessen the risk of GVH, donor tissue is
pretreated with anti-thymocyte globulin to
remove donor T cells.
Cyclosporin A is used also
 Transplant complications
Immunosuppressive therapy has increased
the incidence of:
Cervical cancer
Malignant lymphomas (immunoblastic)
Basal and squamous cell carcinomas of the skin
Squamous cell CA is the most common overall
malignancy
Other complications include infection and
bone marrow suppression