transplantation immunology current status
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Transplantation Immunology Current Status. Volker Daniel, MD Institute of Immunology, Department of Transplantation Immunology, University of Heidelberg, Im Neuenheimer Feld 305 D-69120 Heidelberg Germany [email protected]. Transplantation Immunology. - PowerPoint PPT PresentationTRANSCRIPT
Transplantation Immunology Current Status
Volker Daniel, MDInstitute of Immunology, Department of Transplantation Immunology,
University of Heidelberg,Im Neuenheimer Feld 305
D-69120 HeidelbergGermany
Transplantation Immunology
• TPL (numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
Transplantation Immunology
• TPL (general aspects, numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
Organ FailureAlternative Treatment Strategies
Mechanical organ replacement• Dialysis, bioartificial liver, cardiovascular device
Artificial organs• Tissue engineering, therapeutical cloning
Organs of other species• Xenotransplantation
Benefit of Transplantation
• nearly unrestricted quality of life
• rehabilitated in profession and social relationships
Expenses
Dialysis Renal transplantation1st year 50,000 € 50,000 €2nd year 50,000 € 2,500 €3rd year 50,000 € 2,500 €4th year 50,000 € 2,500 €
Pioneers of Transplantation
• Joseph Murray (kidney, 1954)• James D. Hardy (lung, 1963)• Richard Lillehei (pancreas, 1966)• Christian Barnard (heart, 1967)• Thomas E. Starzl (liver, 1967)
• Jean Dausset (HLA, 1958)• Jon van Rood (Eurotransplant, 1967)
International Transplant Records
Longest surviving recipient with continuous function:
Kidney 39 yearsLiver 32 yearsBone Marrow 29 yearsHeart 24 yearsPancreas 21 yearsLung 18 yearsIntestine 13 years
Clinical Transplants 2001; 279-318
Postmortale Organspenden (Stand: 02/06)
www.dso.de
www.ctstransplant.org
Transplantation Immunology
• TPL (general aspects, numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
Genetic organization of the MHC in humans and the mouse
HLA class II
Expression of MHC Antigens
MHC subregion H-2 HLA
Tissue distribution of antigen
K, D, L, A, B, C All nucleated cells and platelets, erythrocytes
(mouse)
I-A I-E
D B lymphocytes Macrophages Monocytes
Epithelial cells (?) Melanoma cells
Activated T cells (human)
Association between HLA and
susceptibility to
autoimmune disease
Population studies show association of susceptibility to insulin-dependent diabetes mellitus
(IDDM) with HLA genotype
Family studies show strong linkage of susceptibility to insulin-dependent diabetes mellitus (IDDM) with HLA genotype
Transplantation Immunology
• TPL (general aspects, numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
Microlymphocytotoxicity Assay
Separation of lymphocytes using densitiy gradient centrifugation
Separation of lymphocytes in T and B cells using Dynabeads
Dotting lymphocytes on Terasaki microtrays predotted with HLA antisera, Incubation period of 30 min
Addition of rabbit serum (complement), Incubation period of 60 min
Addition of acridinorange and ethidiumbromide, Incubation period of 15 min
Fluorescence microscopy
Mikrolymphocytotoxicity test
Negative Positive
Molecular-Based Techniques for HLA Typing
• RFLP (Restriction Fragment Length Polymorphism)
• PCR-SSO (PCR - Sequence Specific Oligonucleotide Hybridization)- Dot Blot (Standard Procedure) = amplified DNA is dotted- RDB (Reverse Dot Blot = oligos are dotted)
• PCR-SSP (ARMS) (PCR - Sequence Specific Primers)
• SBT (Sequence Based Typing)
• PCR-RFLP u.a.
HLA-Typing; Degrees of Resolution
Resolution Digits Indication Method
Low 2 kidney Tx, platelettransfusion
serology, PCR-SSO, PCR-SSP,
RFLP
High 4 Bone marrow Tx,forensics, disease
associationstudies
PCR-SSO, PCR-SSP, SBT
Nomenclature of HLA alleles Nomenclature Indicates
HLA the HLA region and prefix for an HLA gene
HLA-DRB1 a particular HLA locus i.e. DRB1
HLA-DRB1*13 a group of alleles which encode the DR13 antigen
HLA-DRB1*1301 a specific HLA allele
HLA-DRB1*1301N a null allele
HLA-DRB1*130102 an allele which differs by a synonymous mutation
HLA-DRB1*13010102
an allele which contains a mutation outside the coding region
HLA-DRB1*13010102N
a null allele which contains a mutation outside the coding region
Polymorphism of HLA June 2006
http://www.ebi.ac.uk/imgt/hla/stats.html
HLA class I
Gene A B
Allele 451 782
Protein 358 672
Nulls 36 25
HLA class II
Gene DRB1 DQB1
Allele 522 71
Protein 430 55
Nulls 7 1
HLA-A HLA-B HLA-DRB11 7 12 8 33 13 411 14 723 15 824 18 925 27 1026 35 1129 37 1230 38 1331 39 1432 40 1533 41 1634 4236 4443 4566 4668 4769 4874 4980 50
515253545556575859677378818283
http://www.anthonynolan.com/HIG/nomenc.html
Full List of HLA-A, -B, and -DR alleles (2 digits) assigned as of April 2003
HLA-B B*0808N B*1508 B*1548 B*1812 B*3506 B*3545 B*3922 B*4032 B*4415 B*4807 B*5129 B*5604
B*070201 B*0809 B*1509 B*1549 B*1813 B*3507 B*3701 B*3923 B*4033 B*4416 B*4901 B*5130 B*560501
B*070202 B*0810 B*1510 B*1550 B*1814 B*3508 B*3702 B*3924 B*4034 B*4417 B*4902 B*5131 B*560502
B*070203 B*0811 B*151101 B*1551 B*1815 B*350901 B*3703N B*3925N B*4035 B*4418 B*4903 B*5132 B*5606
B*0703 B*0812 B*151102 B*1552 B*1817N B*350902 B*3704 B*3926 B*4036 B*4419N B*5001 B*5133 B*5607
B*0704 B*0813 B*1512 B*1553 B*1818 B*3510 B*3705 B*3927 B*4037 B*4420 B*5002 B*5134 B*5608
B*0705 B*0814 B*1513 B*1554 B*2701 B*3511 B*3801 B*400101 B*4038 B*4421 B*5004 B*520101 B*5609
B*0706 B*0815 B*1514 B*1555 B*2702 B*3512 B*380201 B*400102 B*4039 B*4422 B*510101 B*520102 B*5610
B*0707 B*0816 B*1515 B*1556 B*2703 B*3513 B*380202 B*400103 B*4040 B*4423N B*510102 B*520103 B*5611
B*0708 B*0817 B*1516 B*1557 B*2704 B*3514 B*3803 B*4002 B*4042 B*4424 B*510103 B*520104 B*570101
B*0709 B*0818 B*15170101 B*1558 B*270502 B*3515 B*3804 B*4003 B*4043 B*4425 B*510104 B*5202 B*570102
B*0710 B*0819N B*15170102 B*1560 B*270503 B*3516 B*3805 B*4004 B*4044 B*4426 B*510105 B*5203 B*5702
B*0711 B*1301 B*1518 B*1561 B*270504 B*3517 B*3806 B*4005 B*4045 B*4427 B*510201 B*5204 B*570301
B*0712 B*1302 B*1519 B*1562 B*270505 B*3518 B*3807 B*40060101 B*4101 B*4428 B*510202 B*5205 B*570302
B*0713 B*1303 B*1520 B*1563 B*270506 B*3519 B*3808 B*40060102 B*4102 B*4429 B*5103 B*5301 B*5704
B*0714 B*1304 B*1521 B*1564 B*2706 B*3520 B*3809 B*4007 B*4103 B*4430 B*5104 B*5302 B*5705
B*0715 B*1306 B*1523 B*1565 B*2707 B*3521 B*390101 B*4008 B*4104 B*4431 B*5105 B*5303 B*5706
B*0716 B*1307N B*1524 B*1566 B*2708 B*3522 B*390103 B*4009 B*4105 B*4432 B*5106 B*5304 B*5707
B*0717 B*1308 B*1525 B*1567 B*2709 B*3523 B*390104 B*4010 B*4106 B*4433 B*5107 B*5305 B*5708
B*0718 B*1309 B*1526N B*1568 B*2710 B*3524 B*390201 B*4011 B*4201 B*4434 B*5108 B*5306 B*5709
B*0719 B*1310 B*1527 B*1569 B*2711 B*3525 B*390202 B*4012 B*4202 B*4435 B*5109 B*5307 B*5801
B*0720 B*1311 B*1528 B*1570 B*2712 B*3526 B*3903 B*4013 B*4204 B*4501 B*5110 B*5308 B*5802
B*0721 B*1401 B*1529 B*1571 B*2713 B*3527 B*3904 B*401401 B*4205 B*4502 B*5111N B*5309 B*5804
B*0722 B*1402 B*1530 B*1572 B*2714 B*3528 B*3905 B*401402 B*44020101 B*4503 B*5112 B*5401 B*5805
B*0723 B*1403 B*1531 B*1573 B*2715 B*3529 B*390601 B*4015 B*44020102S B*4504 B*511301 B*5402 B*5806
B*0724 B*1404 B*1532 B*1574 B*2716 B*3530 B*390602 B*4016 B*440202 B*4505 B*511302 B*5501 B*5807
B*0725 B*1405 B*1533 B*1575 B*2717 B*3531 B*3907 B*4018 B*440203 B*4506 B*5114 B*5502 B*5808
B*0726 B*140601 B*1534 B*1576 B*2718 B*3532 B*3908 B*4019 B*440301 B*4601 B*5115 B*5503 B*5901
B*0727 B*140602 B*1535 B*180101 B*2719 B*3533 B*3909 B*4020 B*440302 B*4602 B*5116 B*5504 B*670101
B*0728 B*15010101 B*1536 B*180102 B*2720 B*3534 B*3910 B*4021 B*4404 B*47010101 B*5117 B*5505 B*670102
B*0729 B*15010102N B*1537 B*1802 B*2721 B*3535 B*3911 B*4022N B*4405 B*47010102 B*5118 B*5507 B*6702
B*0730 B*150102 B*1538 B*1803 B*2723 B*3536 B*3912 B*4023 B*4406 B*4702 B*5119 B*5508 B*7301
B*0731 B*150103 B*1539 B*1804 B*2724 B*3537 B*3913 B*4024 B*4407 B*4703 B*5120 B*5509 B*7801
B*0801 B*150104 B*1540 B*1805 B*2725 B*3538 B*3914 B*4025 B*4408 B*4704 B*5121 B*5510 B*780201
B*0802 B*1502 B*1542 B*1806 B*350101 B*3539 B*3915 B*4026 B*4409 B*4801 B*5122 B*5511 B*780202
B*0803 B*1503 B*1543 B*1807 B*350102 B*3540N B*3916 B*4027 B*4410 B*4802 B*5123 B*5512 B*7803
B*0804 B*1504 B*1544 B*1808 B*3502 B*3541 B*3917 B*4028 B*4411 B*4803 B*5124 B*5513 B*7804
B*0805 B*1505 B*1545 B*1809 B*3503 B*3542 B*3918 B*4029 B*4412 B*4804 B*5126 B*5601 B*7805
B*0806 B*1506 B*1546 B*1810 B*3504 B*3543 B*3919 B*4030 B*4413 B*4805 B*5127N B*5602 B*8101
B*0807 B*1507 B*1547 B*1811 B*3505 B*3544 B*3920 B*4031 B*4414 B*4806 B*5128 B*5603 B*8201
B*8202
B*8301
Full List of HLA-B alleles assigned as of April 2003
New HLA Antigens und Alleles
http://www.ebi.ac.uk/imgt/hla/intro.html
Meyer M, Czachurski D, Tran TH, Opelz G, Mytilineos J.
A new PCR-SSP typing method for six single-nucleotide polymorphisms impairing the blood-clotting cascade as well as T-cell stimulation.Tissue Antigens. 2005 Dec;66(6):650-5.
Czachurski D, Scollo A, Skambraks A, Perichon AM, Scherer S, Tran TH, Opelz G, Grappiolo I, Mytilineos J.
Description and characterization of two new HLA alleles, B*4051 and DRB1*1364, identified by sequence-based typing.Tissue Antigens. 2005 Aug;66(2):151-5.
Czachurski D, Scherer S, Gehrke S, Laux G, Opelz G, Mytilineos J.
Identification of two new HLA alleles: B*3546* and B*5611*. How reliable are the published HLA-B intron 2 sequences?Tissue Antigens. 2004 Oct;64(4):500-5.
Czachurski D, Opelz G, Mytilineos J.
A new HLA-DRB allele (DRB1*15014) identified in a Caucasian individual.Hum Immunol. 2003 Feb;64(2):310-3.
Czachurski D, Rausch M, Scherer S, Opelz G, Mytilineos J.
Characterization of a new HLA-A allele, A*0256, identified in a Caucasian individual.Tissue Antigens. 2002 Aug;60(2):180-3.
Lancet. 2005 Apr 30-May 6;365(9470):1570-6.
Non-HLA transplantation immunity revealed by lymphocytotoxic antibodies.
Opelz G; Collaborative Transplant Study.
Figure 2. 10-year follow-up of kidney grafts from HLA-identical sibling donors
Transplantation. 2002 Apr 27;73(8):1269-73.
Kidney graft failure and presensitization against HLA class I and class II antigens.
Susal C, Opelz G.
Figure 1. Influence of ELISA-detected pretransplant IgG-anti-HLA class I and class II antibodies on cadaver kidney graft survival. Recipients possessing both anti-HLA class I and class II antibodies (I+/II+) had a significantly lower graft survival rate than antibody-negative recipients (I-/II-) (log-rank P <0.0001). Anti-HLA class I-positive/class II-negative (I+/II-) and anti-HLA class I-negative/class II-positive recipients (I-/II+) showed surprisingly good graft success rates.
N Engl J Med. 1994 Mar 24;330(12):816-9.
The influence of HLA compatibility on graft survival after heart transplantation. The Collaborative Transplant Study.
Opelz G, Wujciak T.
Figure 1. Actuarial Survival Rates of First Heart Transplants According to the Number of HLA-A, B, or DR Mismatches. The numbers of mismatched antigens and the numbers of grafts studied are indicated for each curve.
The Eurotransplant International Foundation is responsible for the
mediation and allocation of organ donation procedures in
Austria Belgium Germany Luxemburg The Netherlands Slovenia
In this international collaborative framework, the participants include all transplant hospitals, tissue-typing laboratories and hospitals where organ donations take place. The Eurotransplant region numbers well over 118 million inhabitants.
Eurotransplant
Transplantation Centers
Dialysis Patients on Waiting List
• ABO blood group
• HLA-A, -B, -C, -DR, -DQ alleles
• Panel reactive antibodies
Dialysis Patients on Waiting List
Every 3 months serum screening for HLA antibodies
Results to Eurotransplant
Sera of immunized patients shipped to transplantation centers for future crossmatches
Sensitization Against HLA Antigens
• Previous Transplantation
• Pregnancy
• Blood Transfusions
• Virus Infections
Sensitization of Dialysis Patients
Sensitization Number of Patients (n=358)• 0% 282• 1-10% 33• 11-20% 13• 21-30% 6• 31-40% 5• 41-50% 7• 51-60% 4• 61-70% 2• 71-80% 2• 81-90% 2• 91-100% 1
Retransplants (Kidney)
Previous Transplants Number of Patients (n=358)
0 293
1 49
2 16
3 0
Cross Talk
Eurotransplant
Donor Center Recipient Center
HLA Typing Lab
Kidney DonorABO blood group and HLA typing
Results to Eurotransplant
Crossmatch list from ET with prospective recipients
Crossmatches
Results to ET
Patient with negative crossmatch and highest score receives kidney
Criteria for Kidney Allocation
• ABO blood group• Compatibility in HLA-A, -B, and -DR alleles• HLA mismatch probability• Waiting time• Preservation time• National organ exchange balance
Priority
• Children (<16 years of age)
• Patients immunized against HLA antigens
• High urgency patients
• Patients with combined transplantations
Kidney DonorABO blood group and HLA typing
Results to Eurotransplant
Crossmatch list from ET with prospective recipients
Crossmatches
Results to ET
Patient with negative crossmatch and highest score receives kidney
Crossmatch and Transplantation
Crossmatch Result T B U U + DTT
#Tx, PRA Transplantation
- - - - y+ - + + n+ - + - y+ + + + n- + (+) (+) 1st Tx, <50% PRA y- + (+) (+) >1st Tx, >50% PRA n
T = T lymphocytes; B = B lymphocytes, U = unseparated lymphocytes; DTT = Dithiotreitol#Tx = number of transplantationPRA = Panel reactive antibodiesy = yes; n = no+ = positive; - = negative; (+) = weakly positive
Preservation Time
• Kidney 24 - 72 hours
• Heart 4 - 8 hours
• Liver - 24 hours
• Pancreas - 12 hours
• Lung - 6 hours
Definition of Immunogenetic Relationsship (Transplant - Host)Term Origin of Graft Fate of Graft
Autograft Donor = recipient Transplant is not rejected
Isograft Genetically indenticalindividuals (twins)
Transplant is not rejected
Allograft Genetically differentindividuals of the samespecies
Transplant is rejected after 9-14 days(first set) of accelerated whenretransplant (second set)
Xenograft Different species Transplant is rejected rapidly
Methods of Transplantation
• Cellular transplant: injection of cell suspension
• free transplant: no vascular anastomosis
• stemmed transplant: temporary vascular stem, removed after take of the graft
• organ transplantation: vascular anastomosis
Location of the Transplant
• orthotopic: at the original location
• heterotopic: at another location
Transplantation Immunology
• TPL (general aspects, numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
IL-1
Ag
DC1
IL-1
TH1
TH2
TH2
TH2
B
TH1
TH1
TH1
TH2
TzTz
TzTz
K/NK
Pl
Pl
Pl
AkTs
+ -
IL-2
IL-2
IL-2, IL-12, IFN-y
IL-2, IL-12, IFN-y
Perforin
Granzyme AZz+
IL-4
IL-5
IL-6
IL-10
IL-13
K/NK
K/NKK/NK
Perforin
Granzyme A
Zz+
Tm
Bm
Nekrose
Apoptose
Neopterin
Nekrose
Apoptose
DC2
KomplementlyseOpsonisierung und ADCCPhagozytose
Kinetic of Immune Response
Immunosuppressive Drugs
• Antibodies against lymphocytes(Anti-CD3, ATG, Anti-CD25)
• Calcineurin inhibitors(Cyclosporine, Tacrolimus [=FK-506])
• Corticosteroids
• Antimetabolites (cytotoxic)(Azathioprine, Mycophenolate Mofetil)
Anti-CD3, Anti-CD4, Anti-CD25
• heterologous monoclonal antibodies against lymphocytes
• source: mouse• Induction of ADCC, apoptosis and blockade of cell
function• bridging of activated cytotoxic T cells and T helper
cells killing
• Induction of T suppressor cells
ATG Treatment During Heart Transplantation
0
50
100
150
200
250
300
350
-0,5 0 0,5 4 12 24 72 96
Hours before, during and after transplantation
cells
/µl
CD3 (T cellc)
CD16 (NK cells)
CD19 (B cells)
Recombinant IL-2R Antibody
Anti-IL2R Treatment of Renal Transplant Recipients
0,00
2,00
4,00
6,00
8,00
10,00
12,00
14,00
16,00
18,00
0 7 14 21 28 42 57 72 82 103
Days pre and post transplantation
% C
D3+
CD
25+
T ly
mph
ocyt
es
CD25*A-Region
CD25*B-Region
Corticosteroids
• Inhibit IL-1ß and IL-2 synthesis
• Redistribution of CD4+ lymphocytes from the circulation to other compartments
Mycophenolate Mofetil
• Inhibits T and B cell proliferation by blocking the production of Guanosin nucleotids for DNA synthesis
• Inhibits Inosin-Monophosphat-Dehydrogenase (IMP-DH) and thereby production of Guanosin nucleotids for DNA synthesis
• Specific for IMP-DH-Isoforms in T and B lymphocytes
• Inhibits glycosylation of adhesion molecules ( Attachment of lymphocytes on endothelium, and invasion of leucocytes in allograft)
Cyclosporine
0,0
1,0
2,0
3,0
4,0
5,0
6,0
7,0
8,0
9,0
1 10 100 1000 10000
Days posttransplant
Cy
clo
sp
ori
ne
(m
g/k
g/d
ay
)
Daniel et al., Transplantation 2005, 79:1498
Methylprednisolone
0,0
0,2
0,4
0,6
0,8
1,0
1,2
1,4
1,6
1,8
2,0
1 10 100 1000 10000
Days posttransplant
Met
hyl
pre
dn
iso
lon
e (m
g/k
g/d
ay)
Daniel et al., Transplantation 2005, 79:1498
Mycophenolate mofetil
0
5
10
15
20
25
30
35
40
1 10 100 1000 10000
Days posttransplant
Myc
op
hen
ola
te m
ofe
til (
mg
/kg
/day
)
Daniel et al., Transplantation 2005, 79:1498
Mycophenolate mofetil
0
5
10
15
20
25
30
35
40
1 10 100 1000 10000
Days posttransplant
Myc
op
hen
ola
te m
ofe
til (
mg
/kg
/day
)
Daniel et al., Transplantation 2005, 79:1498
Plasma IL-2
0
5
10
15
20
25
30
35
1 10 100 1000 10000
Days posttransplant
Pla
sm
a I
L-2
(p
g/m
l)
Daniel et al., Transplantation 2005, 79:1498
Plasma IL-10
0
2
4
6
8
10
12
14
16
1 10 100 1000 10000
Days posttransplant
Pla
sma
IL-1
0 (p
g/m
l)
Daniel et al., Transplantation 2005, 79:1498
Steroids
X
IL-1X
IL-1X
XX
Ag
DC1
TH1
TH2
TH2
TH2
B
TH1
TH1
TH1
TH2
TzTz
TzTz
K/NK
Pl
Pl
XAkTs
+ -
IL-2
IL-2
IL2, IL-12, IFN-y
IL-2, IL-12, IFN-y
Perforin
Granzyme AZz+
IL-4
IL-5
IL-6
IL-10
IL-13
K/NK
K/NKK/NK
Perforin
Granzyme A
Zz+
Tm
Bm
Necrosis
Apoptosis
Complement lysis
Opsonization and ADCC
Phagocytosis
Ciclosporine
Steroids
Mycophenolate
Mycophenolate
X
X
X
X
X
XAnti-CD3 mAb
Anti-CD3 mAb
XX
XX
X
Nekrosis
ApoptosisXXX
Mycophenolate
Mycophenolate
XXX
Pl
X
XAnti-CD3 mAb
Steroids
XX
DC2
Steroids
X
http://www.thedrugmonitor.com/transplantpharmacy.html
Transplantation Immunology
• TPL (general aspects, numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
Rejection of Allografts
• hyperacute: within minutes
• acute: 5-9 days posttransplant
• chronic: lingering for weeks and months
Vascular Rejection
Interstitial Rejection
Chronic Rejection
Transplantation Immunology
• TPL (general aspects, numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
Undersuppression
• acute rejection
Oversuppression
• drug toxicity
• infections
• cancer
Cause of DeathFirst Cadaver Kidney Transplant
First Year(n=832)
2 – 5 Years(n=1037)
5-10 Years(n=1063)
Infection 38.1% 16.1% 12.6%Cardiac 22.8% 27.6% 30.5%CVA 6.9% 8.6% 10.9%Cancer 4.5% 16.8% 17.0%
CTS-Study
Posttransplantation Lymphoproliferative Disease (PTLD)
• EBV-induced B cell lymphoma; loss of antiviral control due to strong postoperative immunsuppression
• Reduction or withdrawl of immunsuppressive drugs
Incidence of B Cell Lymphoma
• Normal population: 10/100.000
• During 1. year after kidney transplantation: 250/100.000
• During 1. year after heart transplantation: 1.200/100.000
Am J Transplant. 2004 Feb;4(2):222-30.
Lymphomas after solid organ transplantation: a collaborative transplant study report.
Opelz G, Dohler B.
Figure 1: Ten-year incidence of non-Hodgkin lymphomas (NHLs) in cadaver kidney recipients. Transplants were performed from 1985 to 2001. Expected incidence was based on a nontransplant population of same age and sex distribution and same geographical origin. Relative risk (RR) during the first post-transplant year was 24.6 and yearly RR ranged from 7.3 to 11.2 during the following 9 years.
Lymphocyte Subpopulation Monitoring
• CD3 T lymphocytes
• CD3/25 activated IL-2R+ T lymphocytes
• CD3/DR activated HLA-DR+ T lymphocytes
• CD4 T helper lymphocytes
• CD4/DR activated HLA-DR+ T helper lymphocytes
• CD8 suppressor/cytotoxic T lymphocytes
• CD8/DR activated HLA-DR+ T lymphocytes
• CD16 natural killer cells
• CD19 B lymphocytes
• DR HLA-DR+ monocytes, B lymphocytes, activated Tlymphocytes
J Heart Lung Transplant. 2005 Jun;24(6):708-13.
Effectivity of a T-cell-adapted induction therapy with anti-thymocyte globulin (sangstat).
Koch A, Daniel V, Dengler TJ, Schnabel PA, Hagl S, Sack FU.
Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; Department of Cardiology, University of Heidelberg, Heidelberg, Germany.
BACKGROUND: Cytolytic induction therapy with anti-thymocyte globulin (ATG) should induce effective immunosuppression, with a low rate of rejection in the initial phase after heart transplantation. Induction therapy with ATG allows post-operative renal recovery without the negative effects of highly nephrotoxic cyclosporine levels. An increased rate of infection is a common problem, however, and has been associated with "over-immunosuppression" early after transplantation. Therefore, we investigated whether reduced T-cell-adapted ATG induction therapy could be performed without increasing the risk of graft loss by rejection and whether reductions in infection rates and costs are possible. METHODS: Between March 1999 and December 2002, T-cell-adapted ATG induction therapy with ATG (Sangstat) (1.5 mg/kg) was given to 62 heart transplant recipients (study group) starting on post-operative Days 1 to 6. T-lymphocyte sub-populations were screened daily using flow cytometry. If total lymphocytes were <100/mul (reference 1,300 to 2,300/mul), T-helper lymphocytes (CD4(+)) <50/mul (reference >500/mul) and T-suppressor cells (CD8(+)) <50/mul (reference >300/mul), then no ATG was given. Further immunosuppression was continued with triple therapy consisting of methylprednisolone, azathioprine and cyclosporine. An historic group of heart transplant recipients given a full-dose ATG regimen for 8 days served as controls. These recipients were treated with ATG (Merieux 1.5 mg/kg) until reaching monoclonal cyclosporine levels of >300 mg/dl. Additional immunosuppressive treatment did not differ. Patients in both groups received systemic antibiotics (Imipenem) peri-operatively. Results of routine endomyocardial biopsies and rates of infections were examined. RESULTS: Study group patients were older (52 +/- 10 vs 49 +/- 14 years). In the study group, mean cumulative ATG dose was reduced significantly to 596 +/- 220 mg (p < 0.05) for 3.9 +/- 1.6 days compared with 1,159 +/- 376 mg for 6.9 +/- 1.1 days in the control group. The rate of cytomegalovirus (CMV) seroconversion was 23% in the study group compared with 13% in the control group. Rate of deep sternal infections was lower in the study group (1.6% vs 3.2%). The mean rejection rate in the first 3 months was 0.4 +/- 0.7 for the study patients (185 biopsies) vs 1.1 +/- 1.7 for controls (237 biopsies). All biopsies with ISHLT Grade >2 were treated successfully with 1,000 mg of methylprednisolone intravenously for 3 days. Both groups showed a similar 1-year survival rate (study 88%, control 89%). CONCLUSIONS: T-cell-adapted ATG induction therapy can be a helpful tool for individualized immunosuppression. It is not associated with an increased rate of rejection. Lower doses of immunosuppression help to minimize the rates of infection. In addition, cytolytic induction therapy combined with reduced ATG results in significant cost reduction.
Transplantation Immunology
• TPL (general aspects, numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
Induction of Tolerance
• Clonal deletion• T suppressor lymphocytes• Regulatory T lymphocytes• Antiidiotypic antibodies• Anergy• DC1/DC2 • Microchimerism• Indoleamine 2,3-dioxygenase
IL-1
Ag
DC1
IL-1
TH1
TH2
TH2
TH2
B
TH1
TH1
TH1
TH2
TzTz
TzTz
K/NK
Pl
Pl
Pl
AkTs
+ -
IL-2
IL-2
IL-2, IL-12, IFN-y
IL-2, IL-12, IFN-y
Perforin
Granzyme AZz+
IL-4
IL-5
IL-6
IL-10
IL-13
K/NK
K/NKK/NK
Perforin
Granzyme A
Zz+
Tm
Bm
Nekrose
Apoptose
Neopterin
Nekrose
Apoptose
DC2
KomplementlyseOpsonisierung und ADCCPhagozytose
Mechanism of Self-Tolerance for T Cells
Central (thymic)
• lack of positive selection: before CD4-, CD8-
• clonal deletion: at CD4+, CD8+
• central clonal anergy: at CD4+ or CD8+
Mechanisms of Self-Tolerance for T CellsPeripheral
clonal deletion: irregular activation
• crosslinking CD3/TCR with no APC
• crosslink CD3/TCR and class I together
• independent crosslinking of CD3/TCR and CD4
clonal anergy: incompatible activation
• IL-2 gene silenced
• IL-2 unresponsiveness
• low TCR/CD3
• low CD4/CD8
immunosuppression: complete activation in the presence of negative regulators
• nonspecific factors: TGF-ß, Th1-Th2, steroids
• cognate interactions: idiotypes
compartmentalization
Am J Transplant. 2005 Apr;5(4 Pt 1):746-56
Evaluation of T-cell receptor repertoires in patients with long-term renal allograft survival.
Alvarez CM, Opelz G, Giraldo MC, Pelzl S, Renner F, Weimer R, Schmidt J, Arbelaez M, Garcia LF, Susal C.
The mechanisms underlying long-term acceptance of kidney allografts in humans under minimal or no maintenance immunosuppression are poorly understood. We analyzed the T-cell receptor (TCR) repertoires in circulating T cells of patients with long-term (> or = 9 years) renal allograft survival with (LTS-IS) and without immunosuppression (LTS-NoIS). T cells of LTS patients exhibited strongly altered TCR Vss usage, including an increased frequency of oligoclonality and a decreased frequency of polyclonality. All 3 LTS-NoIS and 12 of 16 LTS-IS patients demonstrated oligoclonality in at least three or more TCR V beta families, and the frequency of oligoclonality in these patients was significantly higher as compared to patients with well-functioning grafts at 3 years (p < 0.005 both), an uncomplicated course during the first year (p < 0.0001, both), acute rejection (p < 0.0001, both), chronic allograft nephropathy at 7 (p < 0.0001, both) or 13 years (p < 0.0001, both), dialysis patients (p < 0.0001, both) or healthy controls (p < 0.0001, both). In contrast to LTS patients, all other studied patient groups exhibited a polyclonal TCR repertoire. Our data indicate that TCR alteration is a common feature of long-term allograft outcome, which might be explained by clonal deletion, exhaustion of alloreactive T cells or predominant expression of particular T-cell subpopulations, such as regulatory T cells.
Figure 3: Percentages of oligoclonality in LTS-IS, LTS-NoIS, WF3, UC1, AR, CAN7, CR13 and dialysis patients and healthy controls.*p < 0.05, **p < 0.01, ***p < 0.001. Median, interquartile range (boxes) and range (whiskers) are shown.
J Exp Med. 1973;137:1142-1162
Identification of a novel cell type in peripheral lymphoid organs of mice. I. Morphology, quantitation, tissue distribution.
Ralph M. Steinman and Zanvil A. Cohn.
During the course of observation on the cells of mouse spleen that adhere to glass and plastic surfaces, it was clear that this population was quite heterogeneous. In addition to mononuclear phagocytes, granulocytes, and lymphocytes, we noticed a large stellate cell with distinct properties from the former cell types. In this paper, we describe the morphology, quantitation, and tissue distribution of this novel cell as identified in vitro. In following papers, we will further characterize it with respect to its functional properties in vitro, as well as its localization and properties in situ.
A dendritic cell sensing a lymphocyteOlivier Schwartz, Virus and Immunity Group, Institut Pasteur, Paris, France
Nature Cell Biology 2004; 6(3):188
Mechanisms of graft rejection
Lechler et al. Nat Med. 2005 Jun;11(6):605-13.
Selected strategies for tolerance induction now in clinical trials.
Lechler et al. Nat Med. 2005 Jun;11(6):605-13.
Kapsenberg, M. L. Nat. Rev. Immunol. 2003; 3:984.
Finding/Hypothesis I
• Myeloid DC (DC1) primed T lymphocytes differentiate into effector CD4+ or cytotoxic CD8+ cells mediating allograft rejection (Zou
et al. J Immunol 2000; 165:4388)
• Plasmacytoid DC (DC2) primed T lymphocytes differentiate into regulatory T cells promoting allograft tolerance (Kuwana et al.
Eur J Immunol 2001; 31:2547)
Rissoan et al., Science 1999; 283:1183
Cella et al., Nat Immunol 2000; 1:305
Finding/Hypothesis II
Immature DCs induce tolerance whereas mature DCs induce immunity.
Steinman et al. J Exp Med 2000; 191:411Dhodapkar et al. J Exp Med 2001; 193:233
Finding/Hypothesis
Tolerance results from: – T cell deletion– T cell silencing – Generation of regulatory T cells
Roncarolo et al. J Exp Med 2001; 193:F5Jonuleit et al. J Exp Med 2000; 192:1213
Generation of tolerogenic/regulatory DC
• Specific culture conditions for propagation of homogenous populations of immature DCs.
• Pharmacological manipulation of DCs to stabilize their immature/tolerogenic phenotype.
• Genetic modification of DCs to impair their stimulating ability/enhance their tolerogenicity.
Raimondi/Thomson; Contrib Nephrol 2005; 146:105
Nat Rev Immunol. 2004 Jan;4(1):24-34.
Dendritic cells: emerging pharmacological targets of immunosuppressive drugs.
Hackstein H, Thomson AW.
Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig University Giessen, Langhansstr. 7, D-35392 Giessen, Germany. [email protected]
Hackstein and Thomson. Nat. Rev. Immunol. 2004; 4:24.
Transplantation Immunology
• TPL (general aspects, numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
Problems of Xenotransplantation
• Natural IgM antinbodies
• MHC incompatibility
• PERVs
• Transfer of virus to human
• Incompatibility in secrected hormones
• Cross-reactive antibodies against MHC
Transplantation Immunology
• TPL (general aspects, numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
Problems of Artifical Organs
• Energy supply
• Blood coagulation
• Replacing only part of organ functions
• Immunization of patient
• Induction of inflammation
Transplantation Immunology
• TPL (general aspects, numbers, overview, history)• HLA• Preoperative tests (prophylaxis of rejection)• Mechanisms of rejection (solid organs)• Immunosuppression• Tolerance (induction)• Clinical complications (infection, cancer)• Bone marrow and stem cell transplantation• Xenotransplantation• Artifical organs
Transplantation of
Bone marrow
• (from hip, narcosis)
Blood stem cells
• (from blood, without narcosis, G-CSF)
Problems of Bone Marrow Transplantation
• HLA-identical donor
• Graft versus host disease
• Host versus graft disease (rejection)
• Infection
Stammzellen
• Adulte menschliche Stammzellen: Sie werden aus Organen gewonnen. Das Arbeiten mit Ihnen ist erlaubt, weil dafür keine Embryonen "verwendet" werden. Die Zellen sind jedoch nicht so wandlungsfähig wie die embryonalen Stammzellen.
• Stammzellen aus Embryonen (ES): Die Zellen können sich in verschiedene Gewebetypen verwandeln. Somit öffnen sich ganz neue Möglichkeiten beispielsweise für die Therapie von Diabetes Mellitus, Alzheimer-Krankheit oder Morbus Parkinson. ES-Zellgewinnung ist jedoch umstritten, weil sie nur aus Embryonen gewonnen werden können. In Deutschland wird zur Zeit aus ethisch-moralischen Gründen darüber diskutiert, ob die deutschen Wissenschaftler für Stammzell Forschung und Gentherapie ES-Zellen aus Israel beziehen dürfen.