C.

G,Vipin Shankar
III Sem MSc. Biochemistry
 Transplantation
 Refers to the act of transferring cells,
tissues or organs from one site to
another.
 The desire to accomplish transplants,
stems from the realization that many
diseases can be cured by implantation
of a healthy organ, tissue or cells (a
graft) from one individual (the donor),
to another in need of the transplant
(the recipient or the host).
 History

Indian mythology
says, Lord Ganesha
has a transplanted
head, and He
remains our favorite
deity….
History…
Sushrutha samhita…
 Sushruta gives accounts of skin
transplantations done on wounded
soldiers.
History…
Alexis Carrel (1908)…
 First systematic study of transplantation.
 Interchanged both kidneys in a series of 9
cats.
 Survived up to 25 days.
 Established that tranplanted organ could
carry out its normal function in a recipient.
History….
Medawar (1940s)…
 Has given insights into nature of graft
rejection while working with burn patients of
World War II.
 Grafts of skin from one region of the body to
another in the same patient was accepted
easily, where as grafts obtained from close
relatives were rejected.
 The intensity of a graft being rejected a
second time was faster.
History…
Medawar…
 Discovered that prior sensitization
with donor cells led to increased
rejection of a subsequent graft.
 The Timeline of Transplantation

 1906 -First corneal transplant by Austrian ophthalmologist

Dr. Edward Zim.

 1908 -First skin allograft by Swiss surgeon Jacques Louis

Reverdin.

 1908 -Successful first cadaver knee joint transplant by Dr

Eric Lexer.

 1911 -Initial use of homologous vein tissue in arterial

reconstruction.

 1918 -First blood transfusion.

The Timeline of Transplantation….
 1949 -Establishment of US Navy Tissue Bank.

 1954 -First successful living-related kidney transplant from

identical twins performed by Dr. Joseph Murray and Dr.
David Hume in Boston, MA. The recipient had normal kidney
function for eight years.

 1955 -Initial fresh heart valve allograft put into descending

aorta.

 1955 -Frozen venous allograft for femoral artery bypass.

 1962 -First fresh heart valves implanted into cardiac

position.
The Timeline of Transplantation….
 1962 -First successful cadaveric kidney transplant by Dr.
Joseph Murray and Dr. David Hume in Boston, MA.  The
recipient had normal kidney function for 21 months.

 1963 -First liver transplant performed by Dr. Thomas Starzl..

 1963 -First lung transplant performed by Dr. James Hardy

at the University of Mississippi Medical Center, Jackson,
MS.

 1967 -First heart transplant performed by Dr. Christian

Bernard at Groate Shure Hospital, South Africa.  The
recipient had normal heart function for 19 months.

 1967 - First successful pancreas transplant performed by

Dr. Richard C. Lillehei at the University of Minnesota.
The Timeline of Transplantation….
 1968 -Brain death criteria created.

 1968 -The Uniform Anatomical Gift Act. Legislation allows

gift of organs to others.

 1971 -Frozen heart valves used in allograft.

 1971 -Introduction of cryo-preserved human skin allografts.

 1972 -The Uniform Anatomical Gift Act establishes the

Uniform Organ Donor Card as a legal document in all 50
states making it possible for anyone 18 years or older to
legally donate his or her organs upon death.
The Timeline of Transplantation….
 1972 -End Stage Renal Disease Act paves way for Medicare
coverage of all kidney transplants.

 1974 -First use of cryo-preserved venous allograft.

 1978 -Cyclosporin begins testing.

 1979 -Living related pancreas transplanted, Minneapolis,

MN.

 1981 -Brain death criteria expanded by President's

Commission for Study of Ethical Problems in Medicine and
Biomedical Research.
The Timeline of Transplantation….
 1981 -First heart and lung transplant performed by Dr. Norman
Shumway at Stanford University Medical Center, Stanford, CA.

 1982 -Barney Clark receives the first permanent artificial heart at

the University of Utah.

 1983 -FDA approval of cyclosporine, the most successful anti-

rejection medication developed to date.

 1984 -First heart / liver transplant performed by Dr. Starzl at the

Children's Hospital of Pittsburgh.

 1984 -Baby Fae receives a walnut-sized baboon heart in an

operation at Loma Linda University Medical Center.  She was the
first infant to receive an animal organ.  Baby Fae lived for 21 days.
The Timeline of Transplantation….
 1984 -National Organ Transplant Act (Public Law 98.507)
establishes nationwide computer registry operated by the
United Network for Organ Sharing (UNOS). The Act also
authorizes financial support for organ procurement
organizations and outlaws purchase or sale of organs.

 1985 -New York State, Oregon, and Pennsylvania pass

Required Request Law. Mandates all potential organ and
tissue donors be approached for donation. Soon thereafter,
all remaining 47 states follow suit.

 1986 -Consolidated Omnibus Budget Reconciliation Act

passed. Requires all potential donors to be approached,
superseding state laws and adding hospitals must comply to
receive Medicare benefits.
The Timeline of Transplantation….
 1988 -FDA approval of Viaspan or UW solution, greatly
extends preservation time for livers.

 1988 -Joint Commission on Accreditation of Health Care

Organizations sets donor identification and notification
standards.  Requires the hospitals to have policies and
procedures in place for the identification, referral and
procurement of organs and tissues.

 1989 -Dr. Thomas Starzl at the University of Pittsburgh

reports clinical success of promising new anti-rejection drug,
FK-506.

 1989 -First liver transplant from a living related donor.

The Timeline of Transplantation….
 1990 -Lung transplantation attempted as cure for Cystic
Fibrosis.

 1990 -Dr. Joseph Murray (performed first kidney transplant)

awarded Nobel Prize for Medicine.

 1990 -Dr. Thomas (pioneered bone marrow transplants as a

cure for leukemia) awarded Nobel Prize for Medicine.

 1990 -First successful heart related lung transplant.

 1991 -First attempt at partial lung transplant.

The Timeline of Transplantation….
 1991 -First successful small intestine transplant.

 1996 -U.S. surgeons at Barnes Hospital in St. Louis,

University of California, San Francisco, and Stanford
University Hospital perform split-liver transplants.
 Classification of grafts
 Autografts: Self-tissue transferred from one body
site eo another in the same individual.
 Isografts: Tissue transferred between genetically
identical individuals.
 Allograft / Homograft: Tissue transferred between
genetically different members of the same species.
 Xenograft / Heterograft: Tissue transferred
between different species.
Autografts and allograftts are usually accepted,
owing to the genetic identity between graft and
host.

Because an allograft is genetically dissimilar to

the host, it is often recognized as foreign by the
immune system and is rejected.

Xenografts exhibit the greatest genetic disparity

and therefore engender a vigorous graft rejection.
 Allograft acceptance
 Histocompatibility & Histoincompatibility.
 Antigens determining histocompatibility: coded by
40 different loci.
 Loci responsible for most vigorous rejection is the
Major Histocompatibility Complex (MHC). ( H2 in
mice and HLA in humans)
 MHC loci is closely linked and is inherited as a
complete set (haplotype) from each parent.
 Allograft rejection
 Rate varies according to tissue involved.
 Skin grafts are rejected faster than kidney or heart
transplants.
 Mechanism of rejection
 Avrion Mitchison (1950) : lymphocytes but not
serum antibody can transfer allograft immunity.
 Rats devoid of thymus can even accept xenografts.
 T cells derived from allograft primed mouse
transfer second set allograft rejection to an
unprimed syngenic recipient.
 Long survival of allografts in children suffering
from thymic defeciancy.
T lymphocytes are involved in graft
rejection.
 Both T cell sub populations CD4 and CD8 are
involved in graft rejection.
 Studied by blocking either of the sub populations
by monoclonal antibodies directed against them.
 Blocking CD8 alone : Graft rejected in 15 days.
 Blocking CD4 alone: Graft rejected in 15- 30 days.
 Blocking both: Graft survived up to 60 days.
Mechanism of graft rejection….
 Primarily by cell mediated immune response to
alloantigen (MHC antigen).
 Both delayed type hypersensitivity and cell
mediated cytotoxicity reactions have been
implicated.
 Two stages involved:
a) Sensitization phase.
b) Effector phase.
 Sensitization phase
 CD4 and CD8 T cells recognize alloantigens.
 Both major and minor histocompatibility
complexes are recognized.
 Recognize both donor MHC and a peptide with in
the cleft.
 Peptide in the cleft in case of MHC I is derived
from protein synthesized by the allogenic cell.
 In case of MHC II, proteins taken up and
processed by the endocyrtic path way of the
allogenic APCs, are bound to the cleft.
 Host TH is activated when it interacts with an APC
expressing an antigen ligand – MHC complex and
also provides a requisite co-stimulatory signal.
 Different cell populations, within the graft serve
as APCs.
 Dendritic cells have high levels of MHC II and
function as major APCs.
 APCs of host origin migrate into graft, endocytose
the foreign antigen and present them as processed
peptides with self MHCs.
 Passenger leukocytes
 A population of donor APCs migrating from the
graft to the regional lymph nodes.
 Primarily dendritic cells with high levels of MHC II
& normal levels of MHC I.
 Wide spread in mammalian tissues except brain.
 Express allogenic MHC Ag.
 Recognized as foreign.
 Stimulate immune activation of T lymphocytes in
lymph nodes.
 Other APCs include:
a) Langerhans cells
b) Endothelial cells lining the blood
vessels.
 These express MHC I and MHC II.
 Recognition of alloantigens induce vigorous T cell
proliferation.
 Major proliferating cell is the CD 4 T cell which
recognizes MHC II directly or alloantigen peptides
presented by APCs.
 Effector phase
 Delayed type hyper sensitivity.
 CTL mediated cytotoxicity.
 Antibody – compliment lysis.
 Antibody dependent cell mediated cytotoxicity
(ADCC).
 Influx of T cells and macrophages.
 Promoted by cytokines produced by TDTH cells.
 Recognition of foreign class alloantigens on th
graft by CD 8 cells lead to CTL mediated killing.
 CD 4 cells function as MHC II restricted cytotoxic
cells responsible for graft rejection.
 Cytokines released by TH cells play central role.
(IL 2, IFN γ & TNF β)
 IL 2 promotes T cell proliferation. Necessary for
generation of CTLs.
 IFN γ promotes development of DTH response,
Promotes influx of macrophages and subsequent
activation of macrophages into more destructive
cells.
 TNF β has direct cytotoxic effect on graft cell,
Induces expression of MHC I and IIon graft cell.
 CD 40 in allograft rejection
 Expressed on wide variety of cells including
dendritic cells, B cells, macrophages and
endothelial cells.
 Critical role in allograft rejection.
 Inhibition of CD 40 with mAbs prolongs rejection
of cardiac allografts and renal allografts.
 Hypothesized that CD 40 has a role in
sensitization phase of T cell.
 Modes of rejection
 Hyper acute rejection.
 Acute early rejection.
 Acute late rejection.
 Chronic rejection.
 Hyper acute rejection
 Occurs within minutes of transplantation.
 Characterized by micro thrombi in capillaries and
sludging of blood cells.
 Caused by pre existing host serum Abs specific for
Ag of graft.
 Ag- Ab complex activates compliment resulting in
intense infiltration of neutrophills into the grafted
tissue.
 Causes massive blood clot in capillaries preventing
vascularization of grafts.
 Presence of Ab against Ag of graft
 Recipients of repeated blood transfusion.
 Repeated pregnancies.
 Previous grafts.
 Specific for blood group antigens.
Rejection of xenografts follow this
mode.
 Accelerated rejection
 A subtype of hyper acute rejection.
 Ab produced immediately after tranaplants.
 Acute early rejection
 Rejection within 10 days or so.
 Severe infiltration of the grafts by mononuclear
cells.
 Rupture of capillaries.
 Involves T cell mediated reactions.
 Acute late rejection
 Rejection from 11th day onwards, in patients
administrated with immunosupressiue drugs.
 Deposition of Immunoglobulins in blood vessel
walls.
 Induce platelet aggrgation in capillaries.
 ADCC occurs.
 Chronic rejection
 Develops months or years after transplantation.
 After acute reaction has subsided.
 Includes both humoral and cell mediated
response.
 Tissue typing
 Identification of HLA in donor and recipient tissue.
 Donor and recipient screened for ABO blood group
compatibility.
 Microcytotoxicity
 WBCs from donor and recipient taken in wells of a
microtitre plate.
 Abs against various MHC I and II Ags are added.
 Incubated for some time.
 Compliment is then added.
 Cytotoxicity assessed by uptake of dye.
 Indicates presence or absence of MHC Ag.
 Mixed lymphocyte reaction (MLR)
 To quantify the degree of compatibility.
 X ray irradiated or mitomicin C treated donor
lymphocytes mixed with recipient lymphocytes.
 Medium contains H3 Thymidine.
 Checked for proliferation of T cells.
 T cell proliferation measured by the amount of H3
Thymidineinto cell DNA.
 Greater the differentiation, more the amount of H3
Thymidine.
 Time consuming.
 Immunosupressive therapy
 Generalised immunosupression of responses to all
antigens.
 Slows down proliferation of activated lymphocytes.
 3 processses
i. Surgical process.
ii. Irradiation.
iii. Drugs.
 Surgical process
 Thymectomy.
 Spleenectomy.
 Lymphadenectomy.
 Total lymphoid irradiation (TLI)
 Lymphocytes are extremely sensitive to radiation.
 Recipient receives multiple x- ray exposure to thymus,
spleen and lymph nodes before transplantation.
 200 rads/day for several days before transplantation.
 Total of 3400 rads.
 Bone marrow not irrradiated.
 Lymphoid stem cells proliferate and renew population
of circulating lymphocytes.
 New lymphocytes are tolerant to Ag of the graft.
 Drugs
 Azathioprine (imuran): mitotic inhibitor.
 Administrated just before transplantation.
 Diminishes T cell proliferation.
 Metabolised to 6-mercaptopurine which is
converted to 6-mercaptopurine riboside.
 Structurally similar to inosinic acid, precursor of
purine biosynthesis.
 Acts as a competitive inhibitor in purine
biosynthesis.
 Both B and T cell proliferation is diminished.
6-mercaptopurine
6- mercapto purine Inosine monophosphate
riboside phosphate
 Cyclophosphamide:
. Alkylating agent.
. Inserts into DNA forming cross links.
. DNA disrupted.
. Effective against rapidly dividing cells.
. Given at the time of grafting.
. Blocks T cell proliferation.
 Corticosteriods
. Prednisone and Dexamethasone.
. Anti inflammatory.
. Exerts effects at various levels of immune
response.

 Cyclosporin A & Rapamycin

. Fungal metabolites
. Has immuno supressive properties.
. Blocks activation of resting T cells.
. Inhibits transcription of gene coding for IL2
receptor (IL2R).
 Specific immunosupressive therapy
 Monoclonal Antibodies directed against various
molecules of immune system.
 Manipulation of CD40.
 Agents blocking co – stimulatory signals.
 Donor treatment with mAbs against T cells.
 Transplants
 Corneal transplants.
 Kidney transplants.
 Heart transplants
 Liver transplants.
 Bone marrow transplants.
 Skin transplants.
 Pancreas transplants.
 References
 Immunology; 5th edition; Richard.A.Goldsby,
Thomas.J.Kindt, Barbara.A.Osborne, Janis Kuby.
 An introduction to immunology; C.V.Rao.
 www.whfreeman.com/immunology5e
 http://www.novartis-transplant.com/
 http://en.wikipedia.org/wiki/Organ_transplant
 http://www.eurotransplant.nl/?id=timeline
Thank you……….