TRANSPLANTATION AND GRAFT REJECTION

TYPES OF GRAFT
1. AUTOGRAFT
The transfer of an individuals own tissues from
one place to place
Ex. Skin graft (regularly accepted)

2. ISOGRAFT
Transfer of tissues between genetically identical
persons
Ex. Identical twins (accepted permanently)

3. ALLOGRAFT/HOMOGRAFT
Transfer of a graft between genetically different
members of same species
Ex. From one human to another
Rejection occur if donor and recipient are not
matched

4. XENOGRAFT/HETEROGRAFT
Transfer of tissues between different species
Always rejected

MECHANISM OF GRAFT REJECTION
1. BOTH TH AND TC ARE ACTIVCATED
TC cells destroys graft cells by direct contact TH
cells secrete cytokines that attract and activate
macrophages, NK cells and polymorph leading to
cellular infiltration and destruction of graft (type
IV)
B cells recognize foreign Ag on the graft and
produce Ab which bind to graft cells and:
o Activate complement causing cell lysis
o Enhance phagocytosis, that is opsonization
(type II)
o Lead to ADCC (Antibody-Dependent
Cell-Mediated Cytotoxicity) by
macrophages, NK cells, and PMNs
Immune complex deposition on the vessel walls
induce platelets aggregation and microthrombi
leading to ischemia and necrosis of graft (type II)

TYPES OF GRAFT REJECTION
1. HYPERACUTE REJECTION
It occurs hours after transplantation
In individual with pre-formed Ab either due to
blood group incompatibility or previous
sensitization by blood transfusion, previous
transplantation
Organ fails to show blood flow, vascular spasms
and vascular occlusion and no perfusion of blood

2. ACUTE REJECTION
It occurs 10-30 days after transplantation
Mainly T-cell mediated
Due to sensitized lymphocyte
Graft is infiltrated with small lymphocyte and
mononuclear cells causing transplant tissue
destruction

3. CHRONIC OR LATE REJECTION
It occurs over a period of month or years
Slow loss of tissue function
It may be cell mediated or Ab mediated or both
May involve weak Ag of HLA system or Ag on
minor MHC loci

4. GRAFT VS. HOST REJECTION (GVH)
An immunologically competent graft is
transplanted into an immunogenically suppressed
recipient (host)
The grafted cells survive and react against the host
cell that is instead of reaction of host against the
graft, the reverse occurs
The GVH reaction is characterized by fever,
pancytopenia, weight loss, rash, diarrhea,
hepatosplenomegaly, and death
Involve the skin, alimentary tract, liver, bone
marrow
Not a problem with heart and kidney

MANAGEMENT OF TRANSPLANT RECIPIENT
Corticosteroid
Anti-metabolites (azathioprine)
Ankylating agent (cyclosphopramide) chemicals
Cyclosporine- affect T cell only
Anti-lymphocyte globulin Antibody
Anti thymocyte globulin


HISTOCOMPATIBILITY TESTING
Cells:
o peripheral blood lymphocyte obtained from lymph
nodes, spleen, or thymus
Procedure:
o Peripheral blood + ficoll hypaque reagent
o Density gradient centrifugation
o Wash cells and resuspend in serum

SEROLOGIC TESTING
Donor and recipient tissues are reacted with a panel of Ab
for various MHC alleles, and their reactions are compared
Sources of Ab:
o Multi-parous women
o Multi-transfused patients
o Volunteers sensitized by transfusions
o Patient with history of transplant rejection

LYMPHOCYTOTOXICITY TESTING
Mononuclear cells are isolated from patient blood
Panel Ab reactive to specific HLA alleles are reacted
Add complement and incubate
Stain with trypan blue or eosin
o Lysed cells will stain blue
o Unaffected cell will not take up the stain
Aliquot of cells is removed and encountered under light
microscope




CELLULAR APPROACH
Based on mixed leukocyte reaction
Donor and recipient cells are cultures together for several
days to allow CD4 cells to be activated and proliferate
Proliferation is measured to product magnitude of rejection
Maybe 1 way MLR or 2 way MLR
ONE WAY MLR
o Test recipient response to donor cells
o Donor cells are irradiated or treated with mitomycin-C
which breaks the DNA so it will not proliferate
o The measured proliferation is recipient cells is response
to CII MHC of the donor
o For bone marrow grafts where donor is alive

MOLECULAR APPROACH
Restriction fragment length polymorphism (RFLP)-
Enzymes cleave genomic DNA to obtain a pattern of
fragmentation (each person has a unique pattern except
identical twins)
Degree of disparity is assessed
Polymerase chain reaction (PCR)
Direct amplification of DNA sequence that border the
gene of interest
Degree of disparity between recipient and donor for
selected sequences is determined
Decrease degree of disparity=decrease/less to be rejected

BIOLOGY OF THE IMMUNE SYSTEM
FATE OF THE ANTIGEN
Depends on the dose and the route or point of entry
Route:
o Bloodstream- to spleen- 1

site
o Skin- localized- inflammatory reaction
o Mucous membrane- GALT/BALT-lymph nodes

ANTIGEN PROCESSING
Ag taken in by macrophage-cytopepsis or fragmented
Coupled with MC II

CELLULAR INTERACTION: 4THEORIES
1. MACROPHAGE: APC
Serves as the accessory cell in the induction of
immune response
2. INDIRECT ANTIGEN FOCUSING
The T cell first bind the Ag in its carrier portion
due to the presence of its receptor
The T cell receptor- Ag complex detaches and
settles to a macrophage exposing the antigenic
determinant
B cells react with the antigenic determinant
3. DIRECT ANTIGEN FOCUSING
Interaction between B cell and T helper cell
T helper cell binds the antigen through its carrier
protein portion and presents the antigenic
determinant to the B cell
4. SIGNAL HYPOTHESIS
They engages the antigen through its carrier
portion and produce a signal known as cytokines
(protein)
B cell joined another antigen molecule will receive
the signal from receptors
CYTOKINE PRODUCED
BCGF
o B cell growth factor
o Stimulate B cell proliferation
BCDF
o B cell differentiating factor
o Induce the activated B cell into and Ab producing
cell

CELL ACTIVATION
T helper cell activation
- The binding of the antigen bring about atleast 2 signals
1. Binding of the T helper cell Ag receptors to the class II
MHC Ag complex being presented by the APC or
macrophage (stronger)
2. Derived from IL-1 which are produced by the
macrophage
*Both will induce the expression of receptors for
lymphokine -2 which serves to amplify the response
initiated by the T helper cell with macrophage
*example: Immunoblast transformation

B-cell activation
- B cell bound to antigen requires a proximate T helper
stimulating signals such as the BCGF and BCDF

Cytotoxic T cell/ Killer cell activation
- Destroy cell that express non-self antigen
- Recognizes the MHCI
- Killer Cell Signals
1. Provide by the interaction of TCR with the foreign
epitope and MHCI on the target cell
2. Provide by IL-2 produced by the activated T helper
cell
*once the signals are received, it will be activated to
produce cytokines effective in the killing of the target
cell

KINETICS: 3 MAIN EVENTS
1. Recognition period
-binding of antigen which takes about 0-24 hour
2. Activation phase
-72-96 hours
3. Differentiation phase
-production of the clones of cells differentiated into
effector cell
-144 hours

PRIMARY IMMUNE RESPONSE
Zero hour
o Ag is introduced- primary event
Primary lag/latent
o Time between the contact of Ag and detection of Ab
in serum
Exponential phase
o Marked by the rapid increase in the titer of the Ab in
circulation
o Ag increase=Ab decrease
Steady phase
o Peak titer is reached
o Ag decrease=Ab steady

Declining phase
o Decreases Ab due to decrease synthesis Ag

Characteristics
o Longer log
o IgM produce first
o IgG produce when IgM reaches its peak
o IgG produce high dose of Ag
o IgM declines first

SECONDARY RESPONSE (ANAMNESIS)
Booster response
Initiated when the Ag is encountered for the second time
Characteristics
o Shorter lag phase due to memory cells
o Shorter period for the Ab production
o IgG is produce 1
st
(easier to produce)
o IgM titer is almost the same as in the primary but IgG
titer is significantly higher
o Earlier decline of IgM than IgG.
o IgG persists vary long in the body within the
protective state
o IgM IgG switch
Significant in disease diagnosis
Manufacture of IgM by a B cell can reverse its
production to IgG
Relatively the same

ABNORMAL RESPONSES OF IMMUNE SYSTEM
Genetic defect or development of infection
Neoplastic disease
Hormonal imbalances bad to immune deficiency
Failure in the self and non-self discrimination
Ex. Development of autoimmune diseases

REGULATION OF THE IMMUNE RESPONSE
1. Ab feedback inhibition mechanism
The Ab when already produced will be able to
destroy the Ag, no more is left to stimulate further
Ab production
2. T-suppressor cells
React to both T and B cells
Direct influence on T helper and B cells
Gives off signals to stop production
3. Idiotype specific regulators
Diversity due to amino acid
10
7
diversity in the body for B cell
When the body encounter the Ag, an anti-
idiotype Ab produced which will be on B cell to
stop
2 Antibody