Dr. ihsan edan abdulkareem alsaimary PROFESSOR IN MEDICAL MICROBIOLOGY AND MOLECULAR IMMUNOLOGY ihsanalsaimary@gmail.com mobile : 009647801410838 university of basrah - college of medicine - basrah -IRAQ

1. Transplantation Immunology
prof.dr.ihsan edan alsaimary
department of microbiology –
college of medicine – university of basrah

2. Transplantation
Summary
 Trends in Survival after transplant
 Donor and Recipient preparation
 HLA Matching
 Surgical Procedure
 Rejection diagnosis and treatment
 Immunosuppression
 Infectious complications after Transplant
 Other complications after Transplant
 Kidney Pancreas Update
 Immunology and Tolerance

3. Scope of problem
 300,000 dialysis patients in US
 55,000 patients on waiting List
 17,000 recovered kidneys per year
 11000 from “deceased donors”
 6000 from living related donors
 1000 kidneys not used after recovery
 Average waiting time 5 years !

4. History of Transplants
 1950’s First attempted in Twins
 Still rejected due to minor antigen differences
 1960’s First success
 Imuran and Prednisone, ATG
 1983 Cyclosporine A introduced
 Dramatic improvement in graft survival
 Opened the era for success in Heart, lung,
liver and other arenas.

5. Survival after Transplant
2003
 Patient Survival 1 yr
 LRD 98%
 DD 95
 Allograft Survival 1 yr
 LRD 95%
 DD 89
 Allograft half-life
 LRD 21 years
 5 yrs
 LRD 91 %
 DD 81
 5 years
 LRD 76%
 DD 61
 DD 13.8 years

6. Transplant survival
 Relative risk of death
 Transplanted in 1993 = 1.0
 Transplanted in 1998 = 0.74
 Currently on Wait list = 1.7
 These are the healthy ones!
 Patients not on wait list = 2.6

7. Trends in Transplantation
 Overall Mortality is unchanged!
 Death with functioning graft increasing
 Donor Age older
 Recipient age is older
 Time on waiting list is longer
 Older, sicker patients are getting
transplants

8. Transplant Update
 Annual Death Rates
 Pts on list 6.3 %
 Diabetic pts on list 10.8 %
 Pts not on list 21 %
 Note that “death censored graft loss” is
standard measure used in transplant
outcome reports since this is desired
outcome.

9. Donor Criteria
 Living related preferred
 Living unrelated next
 Deceased Donor means longer wait
 Brain death required
 No Infection
 No malignancy (except CNS lymphoma)
 Preferrably under 60 years old
 Normal renal function

10. Recipient Preparation
 Dialysis or near Dialysis
 GFR < 15 ml/min
 Compliant with meds and treatment
 Screen for infection, malignancy
 Blood tests and colonoscopy
 Screen for Heart Disease
 Higher risk for dialysis pts
 25 y.o. on dialysis has same risk as 55 y.o.
 Risk for dialysis pt 10 fold higher at any age.

11. Surgical Transplantation
 Procedure time 2 - 4 hours
 Hernia incision to expose Iliac A and V,
extend to expose bladder
 Retroperitoneal so recovery time from
surgery is minimal
 Anastomose Artery and Vein
 Tunnel ureter into bladder
 Lich, Ledbetter

12. Surgical Transplantation
 The native kidneys are left intact
 Unless problems with infection, HTN
 Allograft is easy to palpate, biopsy
 Ureter length is kept short
 Where does the ureter get its blood supply?

13. Surgical Transplantation
 The native kidneys are left intact
 Unless problems with infection, HTN
 Allograft is easy to palpate, biopsy
 Ureter length is kept short
 Dual Blood supply from renal artery and from
cystic artery. Ischemic ureter leads to
stricture or leak.
 Warm ischemia time is kept to < 45 min
 Cold ischemia time up to 72 hours!

14. Surgical Transplantation
 Typical Scenario:
 Multiple organ donor identified, blood typed
 Organ recovery team takes abdominal organs
first, heart and lungs last. (bone skin corneas
may be taken after heart stops).
 Organs are perfused and stored in
preservative solution
 Mixture of high K, antioxidants
 Kept cold on ice.
 Lymph Nodes, spleen used for HLA typing

15. Surgical Transplantation
 Cold Storage limits for organs:
 Heart 6 hours
 Lung 6 hours
 Pancreas 12 hours
 Liver 24 hours
 Kidney 72 hours +
 Primary graft failure rate higher after 72 hrs.
 Tissue weeks to months!
 Bone, skin, cornea, dura mater, etc.

16. Surgical Transplantation
 UNOS master list used to determine where
organs sent, which pts are best match
 Primary patient, plus a standby are called
 Crossmatch takes 6 hours
 Standby used if CM + or primary not available
 A single Txp team could then do
 SPK first (4-6 hours)
 Liver next (8-12 hours)
 Kidney last (2-4 hours)

17. Risk of Graft Loss
 Higher risk
 Deceased donor
 Recipient over 60
 Donor over 60
 Recipient race
 Black / Hispanic
 Long Cold Ischemic
time
 Previous Txp
 High PRA
 Lower Risk
 Living donor
 Recipient under 60
 Donor under 60
 Recipient race
 Asian
 Short cold ischemia
 Higher HLA match
 Low PRA

18. Expanded Donor Kidneys
 Used when risk of Txp is better than life
expectancy on dialysis
 Criteria
 Recipient/donor over 60
 Diabetics over 40
 Failing access for dialysis
 Patient with poor Quality of Life

19. Transplant Update
 HLA Matching
 Main HLA groups A B C D
 C not important for transplant survival
 Host of minor antigens
 Most important antigens are B and D
 A and B are constitutive (always expressed)
 D antigen is inducible and responsible for
more serious (vascular) rejections when it
gets expressed.

20. Waiting list management
 Point system for UNOS Wait list
 1 pt per year on list
 7 pts for 0 mismatch with B, DR antigens
 5 pts for 1 mm with B, DR
 2 pts for 2 mm with B, DR
 4 pts for match in pt with PRA > 80 %
 4 pts for Age < 11, 3 pts for age 11-18
 National sharing of 0 mismatch kidneys
 17-20 % of all transplants

21. Transplant Costs
 Cost:
 Kidney Txp: $ 60,000
 Islet cells 53,000
 Panc Txp alone 105,000
 SPK (K-P) 130,000
 Each year on dialysis: $27,000
 LOS for uncomplicated Kidney:
 5-7 days

22. Typical Kidney Course
0
1
2
3
4
5
6
7
8
1 2 3 4 5 6 7 8 9 10
Typical
Creat
Days after Transplant

23. Delayed Graft Function Course
0
1
2
3
4
5
6
7
8
1 2 3 4 5 6 7 8 9 10
Delayed
Creat
Days after Transplant
Biologic agent used first 10-14 days

24. Rejection
 Clinical Diagnosis:
 Hypertension
 Increased Creatinine
 Decreased urine output
 Biopsy findings:
 Tubulitis – usual Vasculitis - bad
 Interstitial infiltration
 Fixing of C 4 d

25. Rejection Biopsy findings
Normal Cellular Rejection

26. Rejection
 Differential Diagnosis
 Not all ARF is rejection!
 Drug toxicity
 Ureter complication
 Renal Artery Stenosis
 Contrast, Aminoglycoside toxicity
 Tubulo-interstitial Nephritis
 Pre or Post renal causes
 Recurrent disease (late)

27. Pattern of Acute Renal Failure
after Transplant
0
5
10
15
20
25
30
35
40
45
1st
Month
2nd to
6th
6 to 12 after 12
rejection
Drug tox
surgical
ATN
Recurrent
Relative
frequency
Month after transplant

28. Rejection
 4 Types:
 Hyperacute (preformed antibody)
 Screened for with Lymphocyte crossmatch
 Immediate/on the OR table
 Rare due to testing
 ADCC
 Antibody dependent cellular cytotoxicity
 1-4 days post op
 Rare occurance.

29. Rejection
 4 Types:
 Acute
 Most common
 Due to Antigen presentation to an awakened
immune system
 Cellular or Vascular
 Delayed Type or Chronic Rejection
 Must be differentiated from drug nephrotoxicity

30. Rejection and Complement
 Circulating Proteins in blood:
 #1 Albumin
 #2 Immunoglobulin
 #3 Complement, esp C 3.
 Triggers of Complement fixation
 Ischemia reperfusion injury (IP - 10)
 Brain injury in donor
 Dialysis after transplant
 Infection

31. Basic Immunology
 Antigen presenting cells
 Macrophages
 Mesangial cells
 Dendritic/Kupfer cells
 Reticuloendothelial system (RES)
 Endothelial cells and others once injured
 D antigen expression

32. Basic Immunology
 Cell mediated Immunity
 Antigens:
 Viruses, fungi, parasites, intracellular organisms
 T cell lymphocytes
 Cytotoxic
 Directly attack and kill APC, Organism usually
 Helper/ inducer cells
 Recruit more immune cells to respond
 IL-1 and IL-2
 Suppressor cells
 Feedback to modulate immune response
 Important for tolerance.

33. Basic Immunology
 Humoral / Neutrophil system
 Parallel to Cell mediated system
 Antigens:
 Usually bacterial cell polysaccharide
 Antibodies
 Produced by B lymphocytes
 May be specific or nonspecific
 IgG, IgM, others

34. Basic Immunology
 Humoral / Neutrophil system
 Immune complex formation
Occurs when Antigen fixed by antibody
Specificity of ab for ag determines size and solubility
of Immune complex formed
• Immune complex fixes complement
• Complement activation increases clearance of
I-C by spleen, etc
• C3b chemotactic factor for PMN’s
• PMN’s attack with lysozyme

35. Basic Immunology
Antigen Presenting Cell
Antigen plus HLA, coreceptors
Cell Mediated Humoral
Cytotoxic Helper Suppressor Memory
B cell
Fc receptor
comp C3b
Pmn’s
T lymphocytes

36. Memory cell formation

37. Immunology of Rejection
 HLA A and B are constitutive antigens
 HLA D is inducible antigen
 Infection, ischemia induce D antigen
expression
 D antigen expression leads to vascular
rejection which is worst type
 How does Bactrim SS MWF help?

38. Immunology of Rejection
 HLA A and B are constitutive antigens
 HLA D is inducible antigen
 Infection, ischemia induce D antigen
expression
 D antigen expression leads to vascular
rejection which is worst type
 Bactrim SS MWF reduces bacteriuria

39. Immunology of Rejection
 HLA A and B are constitutive antigens
 HLA D is inducible antigen
 Infection, ischemia induce D antigen
expression
 D antigen expression leads to vascular
rejection which is worst type
 Bactrim SS MWF reduces bacteriuria
 What is Acyclovir used for after Txp?

40. Immunology of Rejection
 HLA A and B are constitutive antigens
 HLA D is inducible antigen
 Infection, ischemia induce D antigen
expression
 D antigen expression leads to vascular
rejection which is worst type
 Bactrim SS MWF reduces bacteriuria
 Acyclovir reduces shedding of Herpes Simplex
virus in urine

41. Induction Immunosuppression
 Biological Agents
 Steroid use vs steroid sparing
 Cellcept used in place of Imuran
 Calcineurin Inhibitors / Sirolimus

42. Induction Immunosuppression
 Biological Agents
 OKT-3 rarely used
 Thymoglobulin (rabbit)
 ATG (polyclonal)
 Basiliximab (Simulect) Chimeric
 Anti CD 25/ anti IL-2 receptor monoclonal
 Daclizumab (Zenapax) Humanized
 Anti CD 25 Monoclonal

43. Induction Immunosuppression
 Biological Agents
 Expensive, complex to use
 Use in high risk patients:
 High PRA
 Second transplant
 African American recipient
 Delayed Graft function

44. Induction Immunosuppression
 Biological Agents
 Basiliximab and Daclizumab
 Anti CD 25 monoclonals
 Do not deplete lymphocytes
 Will not stop ongoing rejection
 Other immunosuppression (CNI, steroid, MMF) should
continue during use
 OKT-3, ATG
 Deplete lymphocytes, stop rejection,
 reduce or withhold other immunosuppression while in use

45. Induction Immunosuppression
 New Biological Agents coming soon:
 CTL4 Ig
 stimulates CTL4 coreceptor on T cell which leads
to
 Decreased activation
 Apoptosis of the activated cell line
 LEA 29 Y
 a second generation CTL4 Ig

46. Regulation of T-Cell Activation
APC
T-Cell
CD 40
CTL4
Negative stimulatory
CD 80/86
CD 25
Positive stimulation
IL -2 Receptor
IL-2

47. Induction Immunosuppression
 Biological Agents recommendations
 Low risk patient:
 IL-2 receptor antibody, consider steroid sparing
regimen
 High Risk patient
 Thymoglobulin plus 3 drug regimen
 CNI, Steroids, MMF

48. Maintenance Immunosuppression
 Categories of Agents:
 Steroids
 Calcineurin Inhibitors
 Intracellular signal modifiers
 Cyclosporine, Tacrolimus, Prograf
 Adjuvant Agents
 Interfere with cell cycling
 Sirolimus, Rapamicin
 Cellcept (MMF)
 Imuran (azothioprine)

49. Where the drugs work
 Steroids:
 Toxic to lymphocytes
 Stops rejection
 Inhibits release of IL-1 and IL-2
 Inhibits chemotaxis

50. Where the drugs work
 Cyclosporin A, Tacrilimus
 Neoral, Prograf
 Calcineurin Inhibitors (CNI)
 Multiple effects on proliferating immune cells
 Inhibits m-RNA producing IL-2
 Negligible effect on pre-sensitized cells
 Does not stop ongoing rejection

51. Where the drugs work
 Imuran, Cellcept
 Antimetabolite – blocks purine synthesis
 Interupt cell cycling/proliferation
G 1
S Phase
G 2
Mitosis

52. Where the drugs work
 Rapamicin
 Sirolimus
 Calcineurin inhibitor with novel effects
 Receptor is called TOR
 Similar side effects to CYA and TAC
 May be used in conjunction with TAC and CYA.

53. Maintenance Immunosuppression
 Three Drug Regimen:
 Steroid - prednisone
 Calcineurin Inhibitor
 Cyclosporine, Tacrolimus (Prograf)
 Adjuvant Agent
 Cellcept (MMF)
 Steroid Sparing Regimen:
 Prograf + MMF or Rapamicin

54. Drug Dosages
 Steroid
 10 mg daily or every other day
 CyA
 4-6 mg/Kg/day usually 100 - 150 BID
 Levels 1-6 months: 250 - 400
 Level after 6 months: 100 – 250
 Imuran
 50 – 100 mg daily at bedtime

55. Drug Dosages
 Prograf
 0.1 – 0.2 mg/kg/day
 Usually about 5 mg BID
 Levels 5-15 by ELISA
 Rapamicin
 6 mg po load then 2 mg po daily
 Cellcept (MMF)
 1000 mg BID, taper if low WBC or anemia, GI
intolerance.

56. Drug Conversion for Cause
 Refractory Rejection: CyA -> Tac
 Cardiovasc Dz: CyA -> Tac
 Rapa -> MMF
 Diabetes: decrease steroid dose
 Tac -> CyA may be helpful
 Hirsuitism: CyA -> Tac
 Gout: Azo -> MMF
 Gingival Hyperplasia: CyA -> Tac
 Stop dihydropyridines (procardia XL)

57. Immunology of Rejection
 Tolerance is the best immunosuppression
 Has been known for years
 First seen in pts treated with Steroids/Imuran
 Patients present off all IS with stable renal
function, normal biopsy.
 Cyclosporine seems to impair development of
tolerance
 Has lead to research about T-Cell coreceptors

58. Tolerance Inducing Mechanisms
 T- Cell deletion in Thymus
 Thy – 1 cells lead to rejection
 Peripheral T- Cell deletion
 IL-2 dependent
 FAS dependent
 Veto Cells
 So immune system activation is required but apoptosis is
favored over rejection
 Peripheral Non-deletional mechanism
 Anergy – loss of response to antigen
 Thy 2 cells – regulatory/suppressor cell

59. Tolerance in Practice Today
 For high PRA and Positive Crossmatch pts:
 IVIG/plasmapheresis before and after TXP
 Leads to decrease % Anti-donor antibody
 After Txp, Antidonor Ab returns but does not
lead to rejection
 Anergy
 Increase in Bcl - 2

60. Tolerance
 “Tolerogenic Immunosuppression”
 Rapamicin, Tacrilimus seem to be OK
 Cyclosporine blocks tolerance pathway
 Starzl Lancet 2003
 Sayegh Annals of Surgery 2003

61. Complications of Transplant
 Surgical
 Drug Side Effects
 Infections
 Malignancies
 Cardiovascular
 Bone Disease/hypercalcemia
 Polycythemia
 When to remove the allograft

62. Complications of Transplant
 Surgical
 Wound infection, dehiscence
 Ureter stricture or leak
 Bladder rupture if atrophic
 Renal artery Stenosis
 Renal Vein thrombosis
 DVT
 UTI, Pneumonia

63. Complications of Transplant
 Drug Side Effects
 Hypertension
 Diabetes
 Hirsuitism
 Tremor
 Renal Failure
 TTP
 Anemia/marrow suppression
 GI side effects N/V/D

64. Complications of Transplant
 Infections
 Pattern of infectious complications:
 First 30 days
 Period from 1 – 6 months
 After 6 months

65. Complications of Transplant
 Infections
 First 30 days
 Surgical complications
 UTI, wound, IV sites
 Pre-existing infections in recipient
 C-Dif, CMV, Herpes simplex
 Infection carried from donor
 CMV, West Nile Virus

66. Complications of Transplant
 Infections
 Period from 1 – 6 months
 Here There be Monsters
 Could be anything
 Need to be aggressive and thorough in approach

67. Complications of Transplant
 Infections
 After 6 months, again divides into 3 groups:
 Low risk group
 Low IS load, no serious rejection or infection
 Will mirror general population for the most part.
 High risk group
 Serious or recurrent bouts of rejection
 More prone to fungal, CMV infections
 Chronic infection group
 Need to consider withdrawal of Immunosuppression
 Hepatitis B, C, Difficult CMV, Virus associated
Malignancy.

68. Complications after Transplant
 Malignancy
 Due to reduced immune Surveillance, chronic
virus affects
 Most common is ?

69. Complications after Transplant
 Malignancy
 Due to reduced immune Surveillance, chronic
virus affects
 Most common is ?
 Skin followed by
 Colon
 Lymphoma (Burkitt’s)
 Hepatoma (Hep B)

70. Complications of Transplant
 Hypertension
 Correlates with Age
 Diabetes
 Race
 Graft Function
 CNI use
 Steroids
 Graft Survival reduced if hypertension +

71. Complications of Transplant
 Hypertension
 Target SBP < 130
 Chronic Allograft Nephropathy
 Proteinuria
 Target BP 125 / 75
 Recommended Drugs:
 B blockers
 ACE inhibitors
 CCB’s and diuretics as needed.

72. Complications of Transplant
 New Onset Diabetes after Txp
 NODAT
 Decrease steroids if possible
 Consider Change from TAC to CyA.
 Cardiovascular Risk of a 25 y.o. recipient
 Equal to the risk for a 55 y.o. without renal
disease.
 10 fold higher at any age!

73. Complications of Transplant
 Hyperlipidemia
 Assume CV risk is present
 LDL target < 100
 Consider decreasing Steroids
 Recommend changing CyA or Rapa to TAC.
 Thrombin Activatable Fibrinolysis Inhibitor
 TAFI levels are increased in Txp and Diabetes
 Increase risk of DVT, Unstable Angina.

74. Complications of Transplant
 Post Transplant Bone Disease
 Osteoporosis in 40- 60 % of pts
 BMD decreases 6-10 % per year
 Fractures occurrence Rate
 Diabetics: 40-50 %
 Non diabetics: 10-15 %
 Contributing Factors:
 Renal osteodystrophy, Immunosuppressives
 PTH, Age, Gender, Gonadal Status

75. Complications of Transplant
 Post Transplant Bone Disease
 Treatment
 Calcium 1200 mg Daily
 Vit D 400 – 800 mcg daily
 Exercise, Tai Chi
 Quit smoking!
 Fosamax 70 mg week or 5 mg daily for 6-12
months.
 Hypercalcemia also common

76. Complications of Transplant
 Polycythemia
 Due to extra erythropoietin production
 High Hct, hypertensive
 Treatment
 Phlebotomy
 ACE inhibitor use

77. When to remove Allograft
 Allograft Nephrectomy is indicated:
 Unusual – some pts have more than one
allograft!
 For refractory infection
 Most commonly for terminal rejection, after
graft has failed and pt is back on dialysis
 FUO, FTT, may thrombose or rupture.

78. Transplantation
Summary
 Trends in Survival after transplant
 Donor and Recipient preparation
 HLA Matching
 Surgical Procedure
 Rejection diagnosis and treatment
 Immunosuppression
 Infectious complications after Transplant
 Other complications after Transplant
 Kidney Pancreas Update
 Immunology and Tolerance

79. Kidney – Pancreas Transplant

80. Kidney – Pancreas Transplant
 Rejection Diagnosis:
 Hyperglycemia
 May also occur in face of high steroids, sepsis
 Increased serum amylase level
 Decreased urine amylase level in bladder
anastomosis patients.
 Maintenance immunosuppression
 Tacrolimus/Cellcept preferred combo
 Avoid steroids if possible

81. Kidney – Pancreas Transplant
 Rejection rates improved
 Options for pancreas placement:
 Attach to bladder
 Dumps lots of bicarb, Cystitis
 Easy to identify rejection by measuring urine
amylase
 Attach to intestine (enteric anastomosis)
 Eliminates problems with acidosis and cystitis
 Rejection harder to identify early.

82. Kidney – Pancreas Transplant
 Surgical Complication rate 10% at 1 yr.
 Immunologic Failure Rates:
 Type of Txp % graft loss at 1 yr.
PAK 7 %
PTA 8
SPK 2
Gruessner, Clinical Transplantation 2002, p 52

83. Kidney – Pancreas Transplant
 Effect of Pancreas Txp on outcomes
 No significant QOL improvement compared to
kidney alone
 Insulin free for diabetics 50 – 90 %
 Neuropathy improves
 Microvasculature improves
 Retinopathy – no improvement
 Survival improved compared to wait list pts
 May be slightly better than kidney alone.

84. Ethnic Disparities in Transplant
 Rate of transplantation lower than any
other ethnic group
 % of AA patients hearing about the option
of transplant is only about 70% of other
groups
 Rate of referral once they hear about
transplant is only about 70% of other
groups.

85. Ethnic Disparities in Transplant
 Socioeconomic Factors:
 70% of AA children born into single parent homes
 Less likely to have insurance
 Barriers to travelling to appts
 Less likely to be available when called
 No phone or won’t answer due to debtors
 Higher PRA, fewer AA donors
 Mistrust of system

86. Ethnic Disparities in Transplant
 Insurance Impact on Transplant:
 Compared to pts of other ethnic groups with
same insurance, 70-80 % of eligible AA pts
get to transplant
 HMO rates 70-80 % of eligible pts get to
transplant, evenly across races
 Example of Rationing by Inconvenience
 Military patients demonstrate NO disparity in
rates of transplant or Graft survival.

87. Ethnic Disparities in Transplant
 Immunologic Factors
 Once transplanted, AA pts fare worse
 AA with 0 MM does about as well as Caucasian
with 6 MM and 1 rejection episode in first year.
 Require higher doses of Immunosuppression
 Don’t tolerate steroid or other drug withdrawal
nearly as well as other groups
 Higher levels of IL-6, CD-80, TGF-B, Endothelin,
Renin.
 More Hypertensive, which worsens overall survival

88. Immunology of Rejection
The Future
 Protein Tyrosine Kinases
 Src
 FAK
 Paxillin
 Akt
 PPARS peroxisome proliferator activated
receptors
 Ligands for PPARs tend to decrease inflammatory
response
 Include Piaglitizone, Lopid

89. Immunology of Rejection
The Future
 Chemokine receptors:
 CXC R3 antibody prolongs graft survival in
monkey models
 Also in clinical trials: CCR-1, CCR-5 which
bind CK’s and prevent activation of receptor.
 Soluble Complement Receptor CR-1
 Trypriline decreases synthesis of
complement
 WY14643 ligand for PPAR

90. Immunology of Rejection
 Chemoattractant Cytokines (chemokines)
 Leukocyte recruitment
 Most important CK is CXC
 Receptor is CXC-R3
 Transmembrane protein
 Activation of CXC R3 activates rejection pathway
 IP-10 Activates CXC R3
 Both CXC R3 and IP-10 are present in urine of pts
who are rejecting