Chapter 19
Immunological
Mechanisms of
Transplantation,
Immunohematology,
and Tumour Immunity
Dr Sonal Saxena
Dr Arpita Saxena
A. IMMUNOLOGY OF
TRANSPLANTATION
Transplantation: Transfer of cells, tissues or organs from one
individual to another or from one site to another site in the
same individual
Transplant or graft: The tissue or organ transplanted
Individual from whom the transplant is obtained is known as
the donor and the individual to whom it is applied, the
recipient
Based on the organ or tissue
transplanted: kidney, heart, skin
transplant, etc
CLASSIFICA 2. Based on the anatomical site
TION OF of origin of the transplant and
TRANSPLA the site of its placement
NTS • Orthotopic—grafts are applied in
anatomically ‘normal’ sites, as in skin
grafts
• Heterotopic—grafts are placed in
anatomically ‘abnormal’ sites, e.g.,
thyroid tissue transplanted into a
subcutaneous pocket
CLASSIFICATION OF TRANSPLANTS
3. Based on whether transplants are from fresh tissues and organs or from
stored ones, or whether they are from living or dead materials (cadaveric
transplants)
• Vital grafts—live grafts
• Structural (static) grafts—non-living transplants
4. Based on the genetic (and antigenic) relationship between the donor and the
recipient,
• Autograft—an organ or tissue taken from an individual and grafted on the
same person
• Isograft—a graft taken from an individual and introduced into another
individual of the same genetic constitution,
• Allograft (formerly called homograft)—grafts between two genetically non-
identical members of the same species
• Xenograft (formerly called heterograft)—grafts between members of
different species.
MAJOR
HISTOC • Histocompatibility antigens (alloantigen): cell
surface antigens that induce an immune response
OMPATI leading to the rejection of allografts
BILITY
• Found on the surface of leukocytes
• Human MHC antigens are synonymous with
COMPLE human leukocyte antigens (HLA)
X (MHC)
MHC restriction
• T cell can accept the processed
antigen only if it is presented by
a macrophage carrying on its
surface the self-MHC antigens:
MHC restriction.
MAJOR
HISTOCOMPATIBILITY • Cytotoxic T cells can recognise
COMPLEX (MHC) class I MHC antigens on the
target cells.
• Helper T cells can accept
antigens presented by
macrophages/dendritic cells only
when they bear the same class II
MHC molecules on the surface.
Eichwald–Silmser effect
HISTOCOM
While transplants between members of a
PATIBILITY
highly inbred strain of animals are ANTIGENS
successful, an exception is seen when the
• Antigens that participate
donor is a male and the recipient a female.
in graft rejection are
Such grafts are rejected as the grafted male called transplantation
tissue (XY) will have antigens determined by or histocompatibility
the Y chromosome which is absent in the antigens
female (XX) recipient. Grafts from the female • Major histocompatibility
to the male will succeed. This unilateral sex- system in human beings
linked histoincompatibility is known as the is the human leukocyte
Eichwald–Silmser effect. antigen (HLA) system
TRANSPLANTATION
REACTION
First-set response: Brought about
by T lymphocytes.
• Sensitisation phase: antigen-
reactive lymphocytes of the
recipient proliferate in
response to the alloantigen on
the graft.
• Effector stage (second-set
response): immune destruction of
the graft.
Fig. 19.1 Mechanism of graft rejection
initiated by allogeneic immune response—
sensitisation of the immune cells followed by
effector mechanism leading to acute or
chronic rejection
TRANSPLANTATION
REACTION
Immunological
enhancement: Humoral Allograft immunity is a
antibodies may sometimes generalised response
oppose cell-mediated directed against all the
immunity by inhibiting antigens of the donor.
graft rejection.
IMMUNOLOGICAL BASIS OF ALLOGRAFT REJECTION
1. First set response
Skin graft 2-3 Days
on a genetically Graft vascularised
unrelated animal of and healthy
the same species
4-10 Days
Invasion by After 10 Days
lymphocytes & Thrombosis,
macrophages, ischemic necrosis &
enhanced sloughing of graft
inflammaion
Fig. 19.2 First set rejection: Blood vessels within the graft are occluded by thrombi, the
vascularity diminishes and the graft undergoes ischemic necrosis
IMMUNOLOGICAL BASIS OF ALLOGRAFT REJECTION
2. Second set response
In cases of first graft rejection, the second graft from the
same donor will be rejected in an accelerated fashion;
here, cell-mediated immunity and antibodies are
actively involved in quick graft rejection
Fig. 19.3 Second set rejection- the reactions are rapid with the
involvement of antibodies & cell-mediated immunity, resulting in rejection
of the graft
Hyperacute rejection (white graft response)
IMMUNOL • Graft becomes pale (white graft) and is rejected
OGICAL rapidly
BASIS OF • It occurs in a host with high titres of pre-formed
anti-donor antibodies, wherein activation
ALLOGRA of complement and cell mediated immune
response results into microthrombi and
FT occlusion of vessels
REJECTIO • Can occur in human recipients of kidney
N transplants, with prior transplantation,
transfusion or pregnancy
IMMUNOLOGICAL BASIS OF
ALLOGRAFT REJECTION
Acute rejection
IMMUNOLOGI • It occurs due to incompatibility of
the allograft within 7–10 days after
CAL BASIS transplantation
OF • Graft is rejected due to
ALLOGRAFT accumulation of lymphocytes,
plasma cells, macrophages and
REJECTION neutrophils, leading to endothelial
damage and necrosis
IMMUNOL
OGICAL Chronic rejection
Rejection occurs after 60 days or more, often
BASIS OF superimposed by acute changes initiated by
ALLOGRA infiltration of granulocytes and onset of fibrosis
Example: Kidney transplantation ― there is
FT mesangial cell proliferative glomerulonephritis
REJECTIO and interstitial fibrosis
N
GRAFT-VERSUS-HOST REACTION (GVH)
Graft mounts an immune response against antigens of
the host. It occurs when:
• Graft contains immunocompetent T cells
• Recipient possesses transplantation antigens that are
absent in the graft
• Recipient is incapable of mounting an effective
response against the graft
• Common in stem cell therapy in bone marrow
transplants.
• Two types: (i) acute and (ii) chronic
GRAFT-
VERSUS-
HOST Examples of situations leading to the GVH
reaction
REACTIO
N (GVH) • Allograft in a recipient in whom specific
immunological tolerance has been induced
• Acute or • Adult lymphocytes injected into an
fulminant form: immunologically deficient recipient in
Within the first whom the deficiency is due to immaturity
10 to 100 days (newborn) or immunosuppression
post-transplant • F1 hybrid receiving a transplant from any
• Chronic GVH one parental strain
occurs over three
months to two
years
GRAFT-
VERSUS-
HOST
REACTIO
N (GVH)
Runt disease: It is
a fatal GVH
reaction in
animals with
emaciation,
diarrhea, anemia,
hepatosplenomeg
aly and lymphoid
atrophy Fig. 19.5 Mechanism of graft-versus-host
reaction in three phases of (i) recipients’
conditioning, (ii) donor’s T cell activation and
the (iii) effect
LAB TESTS REQUIRED BEFORE TRANSPLANTATION
1. HISTOCOMPATIBILITY TESTING
• Blood group testing and HLA typing are important in
assessing HLA compatibility before transplantation
Methods of HLA typing
• Micro-cytotoxicity test
• Molecular methods: Restriction fragment length
polymorphism (RFLP), Southern blotting & polymerase
chain reaction (PCR) amplification
LAB Applications of HLA typing
TESTS - Transplantation
REQUIRE - Paternity
D - Anthropological studies
BEFORE - Genetic predisposition to disease
TRANSPL 2. TISSUE MATCHING
•
ANTATIO Mixed lymphocyte reaction or culture (MLR
and MLC)
N
IMMUNOSUPPRESSION FOR SUCCESSFUL TRANSPLANTATION
• Immunosuppression of the recipient is required to
inhibit rejection
• Immunosuppressive drugs:
- Corticosteroids (prednisolone)
- Azathioprine, cyclosporine
- Cyclophosphamide, tacrolimus
• Tissue engineering has a promising role in
transplantation
PRIVILEGED SITES
Allografts survive, safe from immunological attack in
some privileged sites, e.g., fetus, cartilage, testes &
cornea
Probable survival mechanisms:
• Placenta acts as an immunological barrier by
generating a locally immunosuppressive hormone
• Lower densities of major histocompatibility complex
(MHC) antigens on trophoblastic cells
• Relatively resistant to attack by T or NK cells
• Blocking of aggressive T cells by antigens
shed by fetus
• Mucopolysaccharide barrier around
PRIVILE trophoblastic cells
• The high concentration of alpha-
GED fetoprotein in fetal blood which has
immunosuppressive properties
SITES • Areas in which a lymphatic drainage
system is absent (e.g., brain) or
ineffective (e.g., testes) can accept
allografts without rejection
• Fetal stem cells
OTHER • Adult stem cells can also be used,
SOURCES e.g., hematopoietic stem cells in
OF bone marrow transplant in
TRANSPLA hematological malignancies.
NTS • Non-human (xeno) transplants are
still in the experimental stage
POST- TRANSPLANT INFECTIONS
• Risk of infection in a transplanted patient depends on
- Immunosuppression (determines susceptibility)
- Exposure to microbial agents
• Depending on the status of the recipient
i) Early infection which may be related to:
- Healthcare-associated infections
- Donor-associated infection
- Recipient colonisers
- By bacteria(staphylococci) and yeasts (Candida species)
POST- TRANSPLANT INFECTIONS
ii) Second phase: Next 3–6 months
- Viruses: CMV, EBV, herpes simplex virus (HSV),
human herpes virus 6, HBV and HCV
- Fungi: Aspergillus, Pneumocystis jirovecii
- Parasites: Toxoplasma and Strongyloides
iii) Late onset (>6 months):
- Community-acquired infections
- Chronic or progressive viral infections—HBV,
HCV,CMV, EBV, and papillomavirus
- Secondary effects of viral infection
B.
IMMUNOEMATOLOGY
ABO system
The ABO system consists of four blood groups and is determined by
the presence or absence of two distinct antigens, A and B, on the
surface of erythrocytes
Serum contains isoantibodies specific for antigen that is absent in red
cell
Red cells Serum
Group Antigen present Agglutinated by serum Antibody present Agglutinates
of group cells of group
A A B, O Anti-B B, AB
B B A, O Anti-A A, AB
AB A and B A, B, O None None
O None None Anti-A and anti-B A, B, AB
Table 19.1 Distribution of ABO antigens and antibodies in red cells and serum
H antigen: Red cells of all ABO groups possess a
common (universal) antigen, the H antigen; this
antigen is not ordinarily important in grouping or
blood transfusion
IMMUNOHEMATO Bombay/OH blood group: Here, A and B antigens
LOGY as well as H antigens are absent from red cells;
these individuals have anti-A, anti-B and anti-H
antibodies and their sera are incompatible with all
red cells except with same blood group (Bombay
blood)
An anti-Rh factor antibody is present in the
RBCs of most individuals; Rh factor (Rhesus
Rh monkey) is an antigen that reacts with
rabbit antiserum to Rhesus monkey
Blood erythrocytes; ‘hemolytic disease of the
newborn’ is known to occur due to Rh
Group sensitisation
System Typing of persons as Rh-positive or -negative
depends on the presence or absence of
antigen D (Rho) on red cells
MEDICAL IMPLICATIONS OF BLOOD
GROUP ANTIGENS
Blood transfusion
• For routine blood transfusion practice, only ABO and
Rh antigens matching are advised
Choice of donor
• Ensuring that the recipient’s plasma does not
contain antibodies against donor’s RBCs and donor
plasma does not have antibodies that will damage
the recipient’s red cells is important
• O blood group: ‘universal donor’
• AB group: ‘universal recipient’
MEDICAL IMPLICATIONS
OF BLOOD GROUP
ANTIGENS
• Dangerous O groups: Some O group plasma
may contain isoantibodies in high titres (1:200
or above), which results in damage to the
recipient’s cells
• Rh compatibility is important only when the
recipient is Rh-negative
• Cross-matching: It is necessary to perform
cross-matching before transfusion to ensure
that the donor’s blood is compatible with the
recipient’s blood
• Coombs cross-match: Detects all
incompatibilities including incomplete
antibodies
MEDICAL
IMPLICATIONS OF
BLOOD GROUP
ANTIGENS
Hemolytic disease of the newborn
Pathogenesis: Sometimes when an Rh-negative woman
carries an Rh-positive fetus, she is sensitised against the
Rh antigen by minor transplacental leaks at first the
pregnancy; the first child usually escapes harm; however,
during a subsequent pregnancy, Rh antibodies of the IgG
class pass through the placenta and damage the fetal
erythrocytes; for this reason, Rh typing is part of routine
antenatal screening
Clinical features: Accentuation of physiological jaundice,
erythroblastosis fetalis, intrauterine death due to
hydrops fetalis
MEDICAL IMPLICATIONS OF BLOOD GROUP
ANTIGENS
Detection of Rh antibodies
• Rh antibodies can be IgG (incomplete) or IgM
(complete) types
• IgG anti-D antibodies may be detected by
Using a colloid medium such as 20 per cent bovine
serum albumin
Using red cells treated with enzymes such as trypsin,
pepsin, ficin or bromelin
Indirect Coombs test (most sensitive)
MEDICAL IMPLICATIONS OF BLOOD GROUP
ANTIGENS
Treatment
• When diagnosed antepartum, treat with intrauterine
transfusion with Rh negative blood
• Sometimes, premature delivery followed by
transfusion and when baby is born with hemolytic
disease, exchange transfusion with Rh-negative ABO-
compatible blood is suggested
COMPLICATIONS OF
INCOMPATIBLE BLOOD
TRANSFUSION
• Clumping of RBCs & intravascular hemolysis, extravascular lysis
• Symptoms: Shivering, tingling sensation, excruciating headache, constricting
precordial discomfort and severe lumbar pain, hypotension, cold and clammy
skin, cyanosis, feeble pulse, etc.; jaundice, hematuria, oliguria and anuria may
follow
• Reactions due to immunological processes: Rigor, urticaria and other severe
hypersensitive reactions due to hemolysed or contaminated blood transfusion
C. IMMUNOLOGY OF MALIGNANCY (TUMOR IMMUNITY)
• A tumour can act as an allograft and induce
immune response since they acquire new surface
antigens
• Clinical evidence of immune response in
malignancy
• Studies indicate the presence of an immune
response which can prevent, arrest and cure
malignancies
• Spontaneous regression: Neuroblastoma and
malignant melanoma
IMMUNOLOGY OF MALIGNANCY
• Chemotherapy is effective in choriocarcinoma and
Burkitt’s lymphoma; some tumours overcome
defence mechanism and present clinically
• The cellular response resembles that seen in the
allograft reaction; tumours showing such cellular
infiltration have a better prognosis than those that do
not
• Immunodeficiency states are known to have a high
incidence of malignancy, e.g., HIV/AIDS
i) TUMOR-SPECIFIC ANTIGENS
• Tumour-specific transplantation
antigens (TSTA)/tumour-
TUMOUR associated transplantation
antigens (TATA)
ANTIGEN • Found in malignant cells but
S absent in the normal cells
• They induce immune response
when tumour is transplanted in
syngeneic animals
ii) Tumour-associated antigens: Oncofetal antigens are
fetal antigens, which are found in embryonic and
malignant cells but not in normal adult cells are tumour-
associated antigens
Carcinoembryonic antigen is detected in many patients
with metastatic carcinoma of colon, higher levels of
alpha-fetoprotein are found in hepatic carcinoma; these
antigens may have diagnostic value
• Differentiation antigens (prostate-
specific antigen-PSA), may be
higher in patients of prostate
TUMOU cancer and can be a diagnostic
R indicator
ANTIGE • Similarly, CA125
(cancer/carbohydrate antigen 125)
NS is widely used as a diagnostic and
prognostic marker of ovarian
cancer
Humoral immunity
• May not be protective; may even
be detrimental due to its facilitation
of tumour growth by the process of
IMMUNE enhancement
• Anti-TSTA antibodies can be
RESPONSE demonstrated by indirect
IN membrane immunofluorescence &
delayed hypersensitivity to tumour
MALIGNANCY antigens by skin test
Cell-mediated immunity (CMI)
CMI is considered to be protective
against malignancy
Fig. 19.6 Interaction of T
and B cells with tumour
cells
IMMUNOLOGICAL SURVEILLANCE
• Immunological surveillance involves to ‘seek and destroy’ the malignant cells
arising by somatic mutation
• Deranged surveillance mechanism due to ageing or in congenital or acquired
immunodeficiencies leads to increased incidence of cancer
Mechanisms
• Rapid proliferation rate of malignant cells may help them to ‘sneak through’
before an effective immune response
• A large tumour mass may be beyond the scope of immunological attack
Circulating tumour antigens may act as a
‘smokescreen’ coating the lymphoid cells and
IMMUNOLOG prevent them from acting on the tumour cells
ICAL Low immunogenicity of some tumours may
SURVEILLAN suppress CMI
CE Low levels of class I MHC molecules may not
be recognised by CD8+ CTLs for destruction
Passive immunotherapy
• Treatment with specific antisera can help in
regression of tumours by neutralising the
IMMUNO circulating tumour antigens and permitting the
sensitised lymphocytes to act on tumour cells.
THERAPY • Monoclonal antibodies to tumour antigens may
OF play a role as carriers in transporting cytotoxic or
radioactive drugs specifically to the tumour cells
CANCER Specific active immunotherapy
• Purified tumour cell membrane antigens
• Tumour cells treated with neuraminidase
• BCG and non-living Corynebacterium
parvum for malignant melanoma and
intradermal recurrence of breast cancer
following mastectomy
• Dinitrochlorobenzene has been used in
Non-specific the treatment of squamous and basal cell
active carcinoma of the skin
immunotherapy • Glucan from microorganisms, and
levamisole, originally introduced as an
anthelmintic, have been used to
stimulate CMI and macrophage function
• Interferons have been employed in the
treatment of leukemias
Specific adoptive immunotherapy
• Lymphocytes from persons cured of their neoplasms
or specifically immunised against the patient’s
tumour and lymphokine-activated killer (LAK) cells
Immunothe are used in renal carcinomas
Immunomodulation
rapy Of • Immunomodulators have the ability to stimulate
Cancer natural and acquired defence mechanisms, such
as cytokines, which enable the immune system to
help itself
• Immunosuppressive agents and
Immunostimulants
