Transplantation of tissues and organs

 Human tissue replacement requirments

o Transplanted tissue must function normally
o Health of recipient and tissue must be maintained
o Immune system must be prevented for rejection
 Hypersensitivity with transplantation
o Histocompatible  donor tissue and recipient will have a minimal immune response
upon transplantation
 Histoincompatible  non compatible  Leads to immune response called
Hypersensitivity reaction
o 4 kinds of hypersensitivity reactions
 characteristics used by auto immune disease, transplant rejection+
inflammation mechanism]
 Caused by adaptive immune response
 Grouped by effector mechanism of rnx
 Type I hypersensitivity  speed makes it Immediate hypersensitivity
o IgE [Mast cells/eosinophils/basophils]
o IgE act as antigen receptors
 Cross linking causes degranulation
 Release of pro inflammatories
o Severity correlates with location
 Type II-IV  Inflammatory+autoimmune disease+ transplants
 Type II
o Covalent binding to surface of cells  become recognized as
foreign Specifc for antibodies
 B cells recognize isotype  produces IgG
 Sometiems IgM mediates
 Will produce antigen
o Marked for phagocytosis
 Covalent binding acts like a ligand
o Will work within hours
 Type III
o Small soluble immune complexes + IgG {IgM sometimes but less
than type I)
 Can be deposited in small BV+lungs
 Immune complex then activates compliment system
 Leads to inflammatory response that can
damage tissue

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  Associated with therapeutic antibodies from
nonhuman tissue species
 Felt within hours of exposure to the allergen

 Type 4
o Antigen specific T-cell responses
 CD-4 + TH-1 Cells
 CD-8 T CELLS + TH-II cells
o Allergens/oils/metals that penetrate cell membrane
o Covalent molecules  cellular portion recognizes as foreign and
attacks
 Delayed type hypersensitivity (DTH)  1-3 days post
 Blood transfusion
o Most common transplant
 ¼ of ppl will receive blood due to trauma, surgeries, childbirth, etc
 Blood donated is separated into
 Eryhtrocyes
 Plasma

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  Platelets
o Only needed will be transfused
o Short term use, bone marrow will
compensate
o Properties that make it a good tissue for transplantation
 Healthy people can readily donate with little to no harm
 Simple/inexpensive
 Needed for a short period of time  bone marrow will
produce and compensate
 Erythrocytes have little/no MHC-I/II
o Blood transfusion require ABO and RhD match
 Ab’s against immunogenic carbs
 Basic structure for A/B/O same, final addition
different
o A/B have two different structures
o O has none
 Commensal Bacteria induce production of Anti-
A/antiB,
o For O blood type  its against both
 Rhesus D antigen compatibility issue
o If Rh- receives Rh+ pt cannot receive it
again
 Same with pregnancies
 Screen for incompatibility

 Incompatibility of blood group Ag causes type II hypersensitivity rxns

o Transfusion of the wrong blood type leads to a type II hypersensitivity reaction
 Ab coat the rbcs
 subsequent C’ fixation/rapid clearance of cells
 accompanied by fever, chills, shock, renal failure or death
o along with Abo+ RhD , About 30 other blood group antigens are known
 unlikely to cause incompatibility reactions
 cross-match test is performed in lieu of typing donor and recipient for all
possible blood antigens
 recipient’s serum is incubated with donor cells
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  Ab against blood antigen are more frequent in patients who have received
multiple blood transfusions
 Complications in finding nonreactive donor
 Hyperacute rejection of transplanted organs is a type II hypersensitivity rxn
o ABO Ag are also expressed on the endothelial cells of blood vessels
 Issue in highly vascularized tissue
 If type O receives A blood type
o Antigens will bind to BV and compliment active
o Successful transplantation of solid organs depends on ABO antigen matching
 hyperacute rejection: rapid rejection of a graft resulting from a type II
hypersensitivity reaction in which preformed antibodies respond against donor
tissue antigens
 Hyperacute rejection can also be caused by HLA antibodies
o Antibodies against HLA molecules can also cause hyperacute rejection
 most often HLA I variants; sometimes HLA II variants
 bc HLA1 molecules are constitutively expressed on vascular
endothelium as well as nearly all other cell types
 HLA 2 not normally on endothelial cells
o Can be iunduced by infection/formation/trauma
 Occurs during tranpslantations

o Cross-match test is used to detect donor-specific anti-HLA antibodies

 blood serum from recipient assessed for Ab that bind to donor lymphocytes
 Use of recipient serum + donor lymphocytes
 anti-HLA-I Ab react with both B and T cells
 anti-HLA-II Ab react only with B cells
 Anti-HLA Ab can arise from multiple sources [Type 2 hypersensitivities]
o Three sources of anti-HLA antibodies
1) Pregnancy
 exposure to paternally-derived fetal antigens during birth
 in most pregnancies  paternal HLA isoforms
o Different than maternal HLA type
 Birth cells +fetal material enter maternal circulation
o Immune response against paternal in sues
 Will complicate future compatible organ transplant
 Not pregnancies
2) Blood transfusions
 HLA-incompatible leukocytes + platelets  Ab specific for donor HLA allotypes
 Multiple transfusion  Ab’s against most of population
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 3) Previous transplants
 Most transplants don’t survive with pt
 Tissue dies early
 Needs new transplant  new anti-HLA Ab produced
o Sensitized to more allyotypes
 Transplants between genetically identical and genetically different individuals have different
terminology
o Autograft: tissue transplanted from one site to another in the same person
 Rare rejection
 Ex. Burn victems
o Isograft (syngeneic transplant): transplant involving genetically identical individuals
 Identical twins
o Allograft (allogeneic transplant): transplant between genetically different individuals
 Common rejection
 Transplantation rejection and GVH disease are type IV hypersensitivity rxns
o Main cuase of HLA molecule formation  genetic differences
o Alloantigens: antigens that vary between members of the same species
o Alloreactions: immune responses provoked by alloantigens
 Two kinds of alloreactions in transplants
 transplant rejection: recipient immune system attacks donated organ
o Use of T cells
 graft-versus-host-disease (GVHD): Mature T cells from hematopoietic cells
attack tissue
o Grafted tissue rejections are Type 4 hypersensitivity reacions
 Transplanted tissues from live donors fare better than cadaveric tissues
o Trauma/Long term absence of blood  ischemia
 Damage BV and tissue
 Endothelium + complement system
 Leads to filtration of leukocytes and production of cytokines
o Condition of recipient also plays a role
 Pt May already be inflamed  desposition of immune complexes
 Organ degeneration
o Successful transplantation of cadaveric organs is restrained by multiple sources of
inflammation
 stress/harm imposed on donor tissue
 condition of recipient
 surgical procedure
o Use of tissue from live donors can improve transplantation outcomes
 minimal ischemia
 reduced inflammation/damage
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  decreased sensitivity to HLA mismatch
 Matching donor & recipient HLA types improves transplantation success
1. Select a transplant donor with HLA I and II as similar as possible
 reduces number of alloreactive T cells
2. Use immunosuppressive drugs to minimize T cell responses

 HOWEVER: The liver can be transplanted successfully across major HLA differences
o The liver can be transplanted across major HLA I and II differences
 HLA type and cross-match NOT evaluated before liver transplantation
 Major differences in HLA 1 and 2 don’t seem to matter in liver
transplant
o Transplant outcome of liver inversely proportional to degree
of HLA match
 ABO blood type is the only genetic factor affecting donor selection
o Liver is resistant to acute and hyperacute rejection
 has specialized architecture and vasculature
 hepatocytes express very low levels of HLA I and no HLA II
 exposed to numerous foreign proteins from the intestines
 Creates an anti-inflammatory environment
o Organ is highly tolerogenic
 Acute rejection is mediated by effector T cells against HLA antigens
o Most organ transplants have some HLA 1 or 2 differences
 Recipient T cell will respond against antigen
o Acute rejection: recipient T cells respond against HLA antigen differences
 CD8 T cells respond against HLA I differences
 CD4 T cells respond against HLA II differences
 a form of type IV hypersensitivity reaction
o Acute rejection takes days to develop
 reduced or prevented by drug intervention
 Drugs before and maintained after transplants
o If rejection  suppressive drugs
 The direct pathway of allorecognition mediates acute graft rejection
o Direct pathway of allorecognition: DCs from donor tissue present Ag on donor MHC to
recipient T cells
 recipient T cells stimulated by direct interaction with HLA molecules expressed
by donor DCs
 How this happens (two theories):
1. alloreactive T cells recognize amino acid polymorphisms on donor MHC molecules
(loaded peptide is unimportant)

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 2. recipient TCR recognizes exposed determinants of peptides presented by allo-MHC
(peptide is all-important)
 This theory makes more sense
 Some will bind peptides being exposed
o Disappears with time
 Donor DC die and replaced by recipient DC
 HLA differences between donor and recipient activate alloreactive T cells
o Mixed lymphocyte reaction (MLR): tests recipient T cells against tissue to be received
(in vitro model of acute graft rejection)
 cellular equivalent to the Ab-oriented cross-match
1. recipient peripheral blood mononuclear cells [lymphocytes and monocytes] (PBMCs)*
cultured with dead PBMC’s from potential organ donor
2. If naïve T cells can recognize allogeneic HLA I and II molecules are activated and divide
3. cytolytic function of T cells is also measured
CD8 Will start killing donor cells
o Cellular equivalent to cross match
o Rarely occur
 Chronic rejection of a graft is also caused by a hypersensitivity rxn
o Chronic rejection is still an issue
o Chronic rejection: rejection characterized
 thickening of vessel walls
 narrowing of graft vasculature lumens
 Leads to loss of blood supply and ischemia
o Months to years
o Anti-HLA I IgG form immune complexes that deposit in the blood vessel
 type III HS reaction?
 The indirect pathway of allorecognition is responsible for chronic rejection
o Indirect pathway of allorecognition: recipient CD-4 T cells recognize donor Ag
processed/presented by recipient’s cells [Unlike type 4 where donor expresses]
1. donor-derived DC/APCs migrate to 2° lymphoid tissues and die
2. recipient DCs take up membrane fragments containing donor HLA molecules
3. HLA molecules are processed and presented to recipient T cells
4. presentation by MHC II stimulates a CD4 T cell alloreaction
5. CD4 T cells initiate an Ab response against allo-HLA molecules
 Indirect allorecognition can give rise to Treg cells
o transfusion effect: development of Treg cells that suppress alloreactive CD4 and CD8
effector T cells
 occurs via the indirect pathway of allorecognition
o Most common in patients who previously received blood transfusions that shared the
same HLA-DR allotype with the transplanted organ
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  Comparison of direct versus indirect allorecognition

 Allorecognition
o Direct  donor T cells mediate
a response
o Indirect  involved in
activating Recipient T cells

 Immunosuppressive drugs make allogeneic transplants possible

o Two main reasons for HLA-mismatch transplants: the number of donors small, number
of transplants needed large
o Use of immunosuppressive drugs is greatest immediately before and just after
transplant
 render pts highly susceptible to infection
 as patient’s immune system accommodates to the graft  ↓ dose of
immunosuppressant
 the immunosuppressant is ↓ to a level that prevents rejection, but sustains
active defenses against infection
o Use of immunosuppressive drugs can be accompanied by increased cancer
 skin and genital tract carcinomas, lymphoma, Kaposi’s sarcoma
 occurs because immunosuppressants also impairs immune surveliants therby
allowing tumor cells to proliferate unchecked.

 Corticosteroids are used to treat many conditions especially transplants to suppress immune
o Corticosteroids - prednisone (pro-drug)
 converted to prednisolone potent synthetic derivative of cortisone
 drug most extensively used in solid organ transplants
 effects are prompt and dramatic
 potent, synthetic derivative of hydrocortisone
 lypophilic bound by Hsp90 conformation change, Hsp90 is released not can
cross and cause change in cell.
 Basically a sledgehammer approach because it affects so many cells.

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 o Approximately 1% of all cell’s genes can be influenced by
corticosteroids.
 Corticosteroids reduce inflammation in multiple ways
o Indications: organ transplants, anything involving inflammation; does “everything”
(inflammatory, immunologic, hematologic, metabolic disorders) (ideally for acute
conditions only)
o Reduce cytokine production by producting IkB which inhibits NFKb
o Reduces inflammation reduces nitric oxide.
o Induces apoptosis in lymphocytes and eosinophils
o Use needs to be sparing as possible only use in acute situations.
 Don’t use long term.
o Side effects (some):
 immunosuppression  behavioral changes  thinning of skin
 hormonal actions  peptic ulcers  paradoxical
lead to clinical  fluid retention leukocytosis
iatrogenic Cushing’s  weight gain (neutrophilia other
syndrome  diabetes wbcs up or down)
 insomnia  loss of bone density
o Why though we are
suppressing them?
 Result of down
regulated adhesion
cells on the endothelial
cells so leuckocytes
retained in blood.

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  Corticosteroids induce demargination resulting in leukocytosis
o Demargination chiefly affects neutrophils resulting in initial leukocytosis
 Down regulation of adhesion molecules so they cant bind to epithelial cells
and escape blood.
 See significantly more wbcs in circulation.
o Neutrophils and monocytes remain high.
o Immunosuppression is not due to decline in white blood cells but due to altered
migration patterns
 aka they cant get out of blood vessel.
 Due to demargination.
 Pre-transplantation induction includes the use of antibodies to deplete leukocytes
o Rabbit antithymocyte globulin (rATG): mixture of high-affinity IgG that binds T cells, B
cells, NK cells, DCs, endothelial cells (poly clonal antibody made in rabbits)
 (CD2, CD3, CD4, CD8, CD11a, CD18, CD25, CD44, CD45, HLA-DR, HLA I heavy
chains, β2-macroglobulin)
 MoA: apoptosis (mainly of T cells) via AICD (Activation induced cell death) &
ADCC (antibody dependend cellular cytotoxicity) ; C’-dependent cytotoxicity
 indications: pre-transplant induction
 adverse reactions: immunosuppression, thrombocytopenia
o Alemtuzumab (anti-CD52): humanized (all except hypervariable regions have been
converted from rat to human genes) rat IgG specific for CD52 (found on most
lymphocytes, monocytes and Mɸ)
 MoA: C’-dependent cytotoxicity (cell surface complex of CD52 + anti-CD52 Ab is
highly efficient at fixing C’)
 indications: T cells cancers, multiple sclerosis, other autoimmune disorders; off-
label: pre-transplant induction
 adverse reactions: immunosuppression (other effects with long-term use)
 Blocking IL-2 signaling prevents T cell activation
o Require a 3rd signal for full activation which is signaling from IL-2 induces activation of
alpha chain through IL receptor. . Initially only thought of two that were needed CD28
and signal through TCR
o Anti-CD25 (alpha subunit of IL receptor bind to it and converts from low affinity to high
affinity. Added after t cell recognizes its antigen) mAb (IgG1) drugs: basiliximab
(chimeric) & daclizumab (humanized)
 MoA: bind high-affinity IL-2 receptors on T cells to prevent receptor binding to
IL-2 (cytokine)
 prevents full activation of T cells
 indications: prophylaxis of acute kidney rejection; as well as relapsing of MS
 adverse reactions: increased risk of infection and some cancers due to
immunosuppression

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  Calcineurin (activated by calcium, NFAT becomes activated by binding to calcineurin, migrates
to nucleus to bind AP1, now complex begins transcribing IL2 gene and a few others.) becomes
inhibitors selectively inhibit T cell activation
o Cyclosporine
 cyclic decapeptide derived from soil fungus
 don’t need to know binding mechanisms of these two but both prevent
activation of NFAT so stop IL2 expression
o Tacrolimus (FK506)
 macrolide isolated from soil fungus
 MoA (both): repression of IL-2 expression driven by disruption of calcineurin
signaling that prevents activation of NFAT and AP-1
 also, reduced xpn of IL-3, IL-4, GM-CSF, TNF-α
 B cell/granulocyte activation also inhibited
 adverse reactions (both): nephrotoxicity, hypertension, ↑ risk of cancer,
immunosuppression (infection)
 Post-IL-2 signal inhibitors also block T cell action
o Sirolimus (rapamycin)
 macrolide isolated from soil bacterium
o Everolimus
 derivative of sirolimus
 MoA (both): block T cell activation after IL-2 binding preventing signal
transduction from the IL-2 receptor that results in cell proliferation
 also block signaling from growth factor receptors ( so can also treat
certain cancers along with suppress immune system)
 indications: prevention of organ transplant rejection; treatment for multiple
cancers
 adverse effects: similar to CsA or tacrolimus but more toxic
 Soluble CTLA4 can block alloreactive T-cell co-stimulation
o Belatacept: fusion protein containing IgG1 Fc region + CTLA-4 binding region =>
prevents CD28 binding (costimulatory regulator needed to activate T cells)
 MoA: inhibits T cell activation by blocking B7 ( on APC) from binding to CD28 on
T cells
 indications: prophylaxis of organ rejection in kidney recipients only
 adverse effects: immunosuppression leading to infections & certain
malignancies, anemia, diarrhea, constipation
 Some cytotoxic drugs kill cells by inhibiting guanine synthesis (fall into sledgehammer
category again)
o Cytotoxic drugs: Interfere with replication so have greatest effect on rapidly dividng
cells (gut epithelium, hair follicles, bone marrow, immune cells responding against
alloantigens)
o Azathioprine (pro-drug)
 first converted to 6-mercaptopurine, then to active metabolites 6-thioinosinic
acid & 6-thioguanine

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  latter two inhibit DNA/RNA replication => inhibit guanine synthesis which
subsequently-- inhibit lymphocyte proliferation; also inhibits Ig production and
IL-2 secretion
 indications: kidney transplant; rheumatoid arthritis (RA); IBD, SLE
o Mycophenolate mofetil (pro-drug)
 converted to active mycophenolic acid: inhibits DNA/RNA replication =>
interferes with guanine synthesis again so it leads to it inhibits lymphocyte
proliferation
 indications: kidney, heart, liver transplants; renal disease due to SLE; Wegener’s
granulomatosis
o main Side-effects (both): damage dividing cells (bone marrow (myelosuppression), gut
epithelium, hair follicles), hepatotoxic so results in:
 anemia, leukopenia, thrombocytopenia, GI issues, hair loss these drugs are also
hepatotoxic.
 Some cytotoxic drugs kill cells by inhibiting DNA synthesis in other ways
o Cyclophosphamide (pro-drug)
 converted to active form phosphoramide mustard (what defines a mustard is
presence of two chloroethyl groups aka CH2CH2Cl)
 inhibits DNA replication by alkylating/cross-linking DNA => inhibits lymphocyte
replication
 indications: organ transplants, SLE, vasculitis, Wegener’s granulomatosis,
multiple cancers
o Methotrexate
 inhibits DNA replication by inhibiting thymidine synthesis => decreases
lymphocyte replication; inhibits proinflammatory cytokines; promotes apoptosis
of inflammatory cells
 indications: multiple cancers; first-line drug for many rheumatoid diseases
(psoriasis, IBD, vasculitis); organ transplants
o main Side-effects (both): similar to first two drugs on previous slide; cyclophosphamide
is not hepatotoxic but can cause hemorrhagic cystitis
 Summary: stages where drugs act in activation of alloreactive T cells

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In class

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Transplant Immunology and Antirejection Drugs

1. The Kell antigen is a polymorphic antigen, like the ABO and RhD antigens, that is found on red
blood cells. What test, if any, should be performed to detect antibodies against it for use in a
transplant?
a. A test is not necessary since it is a minor blood antigen
i.
b. Cross match test using recipient cells and donor serum
c. Cross match test using recipient serum and donor cells
i. This is the correct answer
ii. We are looking for antibodies in the blood of the recipient
iii. About 30 other blood group antigens are known
1. Unlikely to cause incompatibility reactions
2. Cross match test is performed in lieu of typing donor and recipient for all
possible blood antigens
a. Recipient serum is incubated with donor cells
d. Mixed lymphocyte reaction using irradiated recipient cells and normal donor cells
e. Mixed lymphocyte reaction using normal recipient cells and irradiated donor cells
2. Graves' disease is an autoimmune condition mediated by agonistic autoantibodies directed
against the TSH (thyroid stimulating hormone) receptor. Consequently, the autoantibodies mimic
the natural ligand and induce chronic overproduction of thyroid hormones resulting in

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 hyperthyroidism. What type of hypersensitivity reaction most likely mediates development of
Graves' disease?
a. Type 1
b. Type 2
i. This is the answer
ii. We are talking about antibodies so it can be type 2 or 3
iii. These antibodies are binding to the surface of thyroid cells so therefore it is a
type 2 reaction
iv. If it was in the plasma it would be type 3
v. Graves disease is caused by agonistic autoAb against the TSH receptor
1. Graves disease: autoAb bind the TSH receptor mimicking the natural
ligand
vi. Type 2 hypersensitivities involve interactions of Ab and surface antigens of cells,
follow by complement-assisted lysis of cell
c. Type 3
d. Type 4 mediated by CD4 T cells
e. Type 4 mediated by CD8 T cells
3. A donor kidney was found for a patient in severe need of a transplant. Remarkably, all HLA
molecules were a perfect match. However, the donor had a different blood type. Which of the
following is the most prudent course of action?
a. Administer higher doses of anti rejection drugs for both induction and maintenance
b. Administer a blocking agent specific for CXCL8
c. Continue looking for a suitable kidney donor
i. This is the answer
ii. If you put the wrong blood type in a person it will cause a hyper acute rejection
which is type 2 hypersensitivity reaction- rapid rejection of a graft in which
preformed antibodies respond against donor tissue antigens
iii. Antigens A, B, and O are on the vasculature of epithelial cells
d. Pre-condition both the donor and the recipient with massive quantities of anti-
inflammatory drugs then proceed as normal
e. Remove the patients blood and replace it with the same type the donor has during the
transplant
f. Thoroughly flush the donor kidney multiple times with sterile saline to remove all traces of
donor red blood cells
4. A woman experiencing acute liver failure requires a liver transplant immediately. She has blood
type A+. Her husband, who is in excellent health, offered to donate part of his
liver. Unfortunately, he and his wife have no HLA molecules in common and he has type O+
blood. The woman's sister also volunteered to donate part of her liver. The sister has six HLA
molecules in common with the woman, and her blood type is B+. What would be the best next
step to help the woman who will die imminently without a transplant?
a. Use either liver but with large amounts of antirejection drugs
b. Use neither the husband’s or sister’s livers, and add the woman to the priority liver
transplant waiting list
c. Use the husbands liver but with large amours of antirejection drugs
d. Use the husbands liver with normal drug protocols
i. This is the answer
ii. Liver’s do not have to have the same HLAs, but the blood types need to match or
be compatible
iii. The liver is highly toleragenic

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 e. Use the sister’s liver but with large amounts of anti rejection drugs
f. Use the sister’s liver with the normal drug protocol
5. A 32-year-old man who had received a kidney transplant one week previously began to exhibit
symptoms of rejection, so he was given prednisone and i.v. monomurab, a chimeric anti-T cell
monoclonal antibody. His symptoms resolved, so the steroid and monomurab were
discontinued and his antirejection meds were adjusted accordingly. One month later, he again
exhibited signs of acute rejection, so the same drugs were administered. About 12 hours after
taking the two drugs, he spiked a fever of 104°F and developed a rash on his trunk (see
image) and complained of pain in his joints. His doctors determined that he was experiencing an
extreme hypersensitivity reaction. What type of hypersensitivity reaction most likely led to the
new symptoms experienced by the patient?

a. Type 1
b. Type 2
c. Type 3
i. This is the correct answer
ii. The initial exposure sensitized him to the chimeric antigen (part human and part
mouse)
iii. When administered again his antibodies reacted and they can tend to
accumulate at the joint
iv. The bind to minamura and make the immune complexes that traverse the body
v. Type 3 reaction results from small soluble immune complexes (soluble proeint
Ag and IgG)
vi. Immune complexes become deposited in tissue (walls of small blood vessels,
glomeruli, joints)
vii. Immune complexes activate C’ and initiate inflammatory responses that damage
tissues
viii. Often associated with therapeutic Ab or other proteins derived from nonhuman
species
d. Type 4 mediated by CD4 T cells
e. Type 4 mediated by CD8 T cells
6. Seven years following a kidney transplant, a 36-year-old woman saw her physician because she
noticed a slight brown color in her urine. Urinalysis revealed hematuria but cultures were
negative. Blood work showed a urea level of 89 mg/dl (normal: 7-20) and a creatinine level of

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 3.1 mg/dl (normal: 0.5-1.1). Biopsy of the allograft revealed mild mononuclear cell infiltrate
accompanied by moderate interstitial fibrosis and tubular atrophy. What cell type most likely
initiated the rejection events?
a. Donor CD4 T cells
b. Donor CD8 T cells
c. Donor DC
d. Recipient CD4 T cells
e. Recipient CD8 T cells
f. Recipient DC
i. Dendritic cells present the antigens
ii. Donor cells should no longer be there
iii. CD4 and CD8 cells are in acute graft rejection and take a few days
1. Direct pathway of alloregocnigtion: DCs from donor tissue present Ag
iv. Chronic rejection takes years and that is due to type 3 and is due to recipient
dendritic cells
1. Processed and presented to recipient T cells
7. What is the purpose of irradiating donor PBMCs for the mixed lymphocyte reaction assay?
a. To ensure the donor cells are sterile before culturing them
b. To induce upregulation of MHC expression on donor cells
c. To kill donor antigen presenting cells so that only T cells responses will be apparent
d. To prevent proliferation of donor T cells
i. This is the answer
ii. Mixing two populations of T cells (donor and recipient) they express different HLA
molecules and if T cells see a difference they respond
1. We want to see what is responding which is the recipient and they start
to divide and kill stuff and we need to limit the donor one in this case and
so they will not divide and the recipient ones can still divide in this case
iii. MLR: assess extent to which a patient’s T cells will respond to transplanted
tissue
e. To kill any residual red blood cells remaining after PBMC purification
8. Individuals infected with virus Z experience extreme inflammation in their brains resulting in
a severe autoimmune attack on the CNS that leads to sudden and apparent death. However,
a "post-mortem" cytokine surge "jump-starts" the surviving brain cells so that infected individuals
regain consciousness and limited awareness accompanied by primordial
behavior. Administration of massive doses of steroids to stem the course of the disease is
useless. What is the best explanation for this?
a. Virus Z causes mutation of the CD28 gene
b. Virus Z causes mutation of the CD52 gene
c. Virus Z causes mutations of the Hsp90 gene
i. This is the answer
ii. Steroid receptor is bound to Hsp90 and if there is a mutation is Hsp90 the steroid
will not have any affect
d. Virus Z causes mutation of the IL-2 receptor
e. Virus Z causes upregulation of the thymidine synthesis
9. Which of the following drugs most likely can be used to treat non-hematopoietic cancers?
a. Basilliximab
b. Cyclosporin
c. Daclizumab

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 d. Sirolimus
i. This is the answer
ii. Block T cell activation after IL 2 binding presenting signal transduction from the IL
2 receptor that results in cell proliferation and also block signaling from growth
receptors
iii. This is a treatment for multiple cancers
iv. Target pathway for presentation of graft rejection has elements in common with
pathways used in growth factors
e. Tacrolimus
10. Which of the following drugs is best to use as adjunct anti-rejection therapy for a kidney
transplant patient who has mild liver cirrhosis?
a. 6-thionisinic acid
b. Azathioprine
c. Cyclophosphamide
i. This is the answer
ii. Only one without liver toxicity
iii. Can cuase hemorrhagic cystitis
d. Methotrexate
e. Mycophenolate mofetili

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