Transplantation

Xiang Li, Urology Department West China Hospital, Sichuan University

Acknowlegement

To Dr. Lu Yiping and Dr. Wang jia To other Colleagues working on renal and liver transplantation

Transplantation is a Dream?
  

Dream of Paranoia Dream of excellent surgeon who wants to excel himself. Dream of excellent scientist who believe nothing is impossible.

Can you imagine? Can you imagine? Can you imagine?

Contents
 

Basic concepts of transplantation Clinical Organ transplantation

Renal Transplantation, RT MHC and Tissue Matching Graft Rejection Immunosuppression

Transplantation Immunology
  

Definition of Transplantation
 

 

Implantation of non-self tissue into the body the process of taking cells, tissues, or organs called a graft (transplant), from one part or individual and placing them into another (usually different individual). donor : the individual who provides the graft. recipient or host: the individual who receives the graft.

Blood Transfusion
 

First attempts were unsuccesful (MISMATCH) Discovery of blood groups (Red cell antigens)
A-B Landsteiner 1900  Rh Levine, Stetson 1939


Succesful transfusion = Transplantation

 

Others: Bone, Tissue-engineering, etc Transplantation

Organ Transplantation

Types
   

Autologous graft (autograft) : within an individual, autotransplantation Syngeneic graft (syngraft, isograft) : identical twins, isotransplantation Allogeneic graft (allograft, homograft) : non-identical, allotransplantation Xenogeneic graft (heterologous graft, heterograft) : between species, xenotransplantation

Classification of Renal Transplantation

Auto-RT Cadaveric Allograft RT Living Donor Living related

Living unrelated Xenograft RT (In experimental)

Transplantation History
  

experimental kidney transplantation -1912  Alexis Carel-Nobel prize 1935 human kidney transplant in Russia - rejection P.B. Medawar (1945) skin grafts  Self skin accepted  Relative not accepted ! What is the difference ?  Immunologic mechanism A. Mitchison (1950)  Lymphocytes are responsible for rejection

Transplantation History
 

Peter Gorer (~1935)  Identification of 4 group of genes for RBC Gorer and Gorge Snell (~1950)  Group II antigens are responsible for rejection  Major HistoCompatibility genes (HLA)  Nobel prize 1980 George Snell 1954 Succesful kidney transplant between identical twins in Boston Peter Bent Brigham Hospital  Joseph Murray 1991 Nobel prize

HISTORY OF THE RT
   

1933 1954 1958 1959

     

First clinical RT (Voronov); First long-term successful RT(Twin); Discovery of HLA(Human Lym Antigen); Radiation be used for immunosuppression; 1961 Azathioprine (Aza); 1962 Prednisolone; Tissue Matching; 1966 Cross-Matching; Late 1960 Preservation the Kidney>24hr ; 1972 First successful RT(LRD) in china; 1978 Clinical use of Cyclosporine(CsA).

Key factors for succesful transplantation

Knowledge of MHC haplotypes Effective immunosuppression Ability to identify and treat infections Available donors

Applications of allografting transplantation

The importance of transplantation:

Clinical Organ Transplantation

Liver Transplantation Renal Transplantation

LIVER TRANSPLANTATION
 

Indication: End stage liver diseases (ESLD) Hepatic Disease to ESLD

Congenital malfomation; Congenital liver metabolic disorders; Acute liver failure; Chronic liver failure: (1) Cirrhosis: Hepatitis B, Alcoholic; (2) Parasites: Hydatid disease of liver, ect. liver malignance

RENAL TRANSPLANTATION
END STAGE RENAL DISEASES (ESRD) Definition: (1) Various causes; (2) Irreversible injury; (3) Functional failure. Morbidity
 

Europe: 50/million; China: 90-100/million

TREATMENT OF ESRD


DIALYSIS Chronic Ambulatory Peritoneal Dialysis (CAPD); Hemodialysis (HD).

KIDNEY TRANSPLANTATION

Renal Transplantation


Renal transplantation is associated with as survival benefit for patients with ESRD when compared to dialysis; Even marginal donor kidneys confer a significant survival advantage over maintenance dialysis. The preferred therapy for most of the Pts with ESRD; More cost- effective; Better survival; Better life quality.

CONTRAINDICATION
    

Active invasive infection; Active malignance; High probability of operative mortality; Unsuitable anatomic situation for technical success; Severe psychological or financial problem.

Pre-OP Selection
 

ABO Blood Group: Compatible; Cytotoxicity Test: Donor Lymphocyte Recipient Serum Recipient Serum Cross matching Donor Lymphocyte Donor Serum Recipients Lymphocyte

 

Mixed Lymphocyte Culture Tissue typing (HLA)

OPERATION DONOR (1) Living donor

Nephrectomy via flank approach; Nephrectomy via Laparoscope.

(2) Cadaveric Donor

Total midline incision; in situ flashing: Euro-collins/UW solution; Bilateral radical nephrectomy. Low temperature preservation.

 

Potential Advantages of living versus cadaveric kidney donor

Better short-term result(about 95% versus 90 % 1-yr function); Better long-term results(half-life of 12-20 yr versus 8-9 yr); More consistent early function and easy of management;

Potential Advantages of living versus cadaveric kidney donor

Avoidance of brain death stress; Minimal incidence of delayed graft function; Avoidance of long wait for cadaveric transplant;

Potential Advantages of living versus cadaveric kidney donor

Capacity of time transplantation for medical and personal convenience; Immunosuppressive regime may be less aggressive; Help relieve stress on national cadaver donor supply; Emotional gain to donor.

Potential disadvantages of live donation

Psychological stress to donor and family; Inconvenience and risk of evaluation process(i.e., intravenous contrast); Operative mortality(about 1 in 2000 Pts.); Major post operative complications (about 2% of Pts.);

 

   

Potential disadvantages of live donation Minor postoperative complications(up to 50% of Pts.); Long-term morbidity(possible mild hypertention and proteinuria); Risk for traumatic injury to remaining kidney; Risk for unrecognized covert chronic renal disease.

Recipient Operation
Extraperitoneally in the contralateral iliac fossa via Gibson incision.

Why contralateral ?

RECIPIENT OPERATION


Blood Vessel Anastomosis:

Donor renal V Donor renal A

Recipientsexternal iliac V Recipients internal iliac A

Ureter Anastomosis:
 

Donor ureter

Recipients bladder

Anti-reflux anastomosis

Clinical phases of rejection

Hyperacute rejection (minutes to hours)

Preexisting antibodies to donor HLA antigens Complement activation, macrophages

2. 3.

Accelerated rejection Acute rejection (around 10 days to 30 days)

Cellular mechanism (CD4, CD8, NK, Macrophages) Mixed humoral and cellular mechanism
CHRONIC REJECTION IS STILL HARD TO MANAGE !

4.

Chronic rejection (months to years !!)

IMMUNOSUPPRESSION


Immunosuppresents play a very important role in organ transplantation; Immuosuppresents extremely increase the effect and the survival rate of organ transplantation;

IMMUNOSUPPRESSION


Immunosuppresents are a double edged sword; the most important thing is to increase their positive effects, and in the same time decrease their side effects (i.e., organ toxicity, infection, tumors, ect.).

Diagnosis of rejection Symptom/Sign

fever; urinary output q; graft tenderness; graft size o; hypertension; myalgia/arthragia.

Laboratory Test  Serum creatine, SCr;  Urinary creatine, Ucr;  Color doppler scan;  radiorenogram;  Ateriogram;  Biopsy: (1) Fine needle aspiration biopsy (FNAB); (2) Core needle biopsy(CNB).

Treatment of kidney rejection

Hyperacute (Sometimes during the operation !)

No therapy, usually results in graft failure kidney should be removed BIOPSY ! Increase immunosuppression
  

Acute (Most frequently in the first 4 weeks)

Increase steroid dose Increase cyclosporin (monitor serum level !) ATG, ALG, OKT3

Chronic
 

ACE inhibitors, prostacyclin analog drugs Steroid, Imuran, Cellcept

Transplantation Immunology

Histocompatibility Antigens


Major histocompatibility antigens

MHC class I molecules :

almost all nucleated

MHC class II molecules :

APCs, endothelium

Minor histocompatibility antigens : HY molecule

Major histocompatibility antigens

Human leukocytic Antigen

HLA I.


( 1, 2, 3, 2-microglobulin) ( 1, 2, 1, 2)

Gene-Code alleles: A, B, C loci Gene-Code alleles: DP, DQ, DR loci Gene-Code alleles: C4A, TNF, HSP70

HLA II.


HLA III.


MHC complex: Gene

Major histocompatibility antigens

MHC loci are highly polymorphic Many alternative alleles at a locus The loci are closely linked to each other A set of alleles is called a HAPLOTYPE One inherites a haplotype from mother and another from father The alleles are codominantly expressed

nheritance of MHC alleles

A/B

C/D

A/C

A/D

B/C

B/D

A/R1

R2/C

R2/R1

Possible children of parents with HLA haplotype A/B and C/D R1=C-D recombination R2=A-B recombination

nduction of Immune Responses Against Transplants

alloantigens and xenoantigens : antigens that serve as the targets of rejection the antibodies and T cells that react against these antigens are said to be alloreactive and xenoreactive, respectively. allorecognition  direct  indirect

Rejection


Senzitization stage Not needed in hyperacute reactions ! Effector stage  Alloantibodies: bind to endothelium, activate the complement system, and injure graft blood vessels

Rejection


Effector stage (Mostly cellular mechanism)  Alloreactive T cells : recruit and activate macrophages ---> DTH response delayed type hypersensitivity


Alloreactive CTLs: CTL mediated cytotoxicity lyse graft endothelial and parenchymal cells directly

ADCC CD4, CD8 lymphocytes, NK cells, macrophages

Rejection

From: Kuby: IMMUNOLOGY (fourth edition, 2000)

Tissue typing


 

Microcytotoxicity assay  Known antibody to WBCs of donor / recipient  Complement mediated lysis if Ab present on cell surface Mixed lymphocyte culture (MLC)  Irradiated donor lymphocytes (stimulants)  Incubated with recipient lymphocytes  3H Thymidin incorporatin measured Flow cytometry cross typing DNA analysis  Genomic typing (very precise, many subtipes)

Hyperacute Rejection
 

Occurs within minutes of transplantation Pre-existing IgM (natural) antibodies against  ABO blood group antigens  less well-characterized antigens in xenograft  alloantigen, such as foreign MHC molecules, or alloantigen expressed on vasular endothelial cells

Hyperacute Graft Rejection

Acute Rejection


Occurs within transplantation

days

or

weeks

after

Acute vascular rejection

Necrosis of cells of the graft blood vessels (vasculitis) Mediated by IgG antibodies against and endothelial cell alloantigens complement activation

Acute Rejection


Acute cellular rejection

Necrosis of parenchymal cells with lymphocyte and macrophage infiltrates Effector mechanisms :
 CTLs  Activated

macrophages  Natural killer cells

Acute Cellular Rejection

Chronic Rejection
   

Occurs over months or years Fibrosis with loss of normal organ structures Wound healing following the cellular necrosis A form of chronic DTH or a response to chronic ischemia caused by injury to blood vessels

Prevention and Treatment of Allograft Rejection1

Immunosuppression
   

drugs that inhibit or kill T lymphocytes toxins that kill proliferating T cells antibodies that deplete or inhibit T cells anti-inflammatory agents

Prevention and Treatment of Allograft Rejection2

Reduce the immunogenicity of allografts

ABO blood group typing HLA typing and matching blood transfusion

induce donor-specific tolerance

Graft-versus-host Disease (GVHD)

Occurs in bone marrow recipients Initiated by T cell recognition of host alloantigens The effector cells are less well defined : NK cells, CD8+ CTLs, cytokines

Acute GVHD


Epithelial cell necrosis :

Skin Liver The gastrointestinal tract

Characterized by skin rash, jaundice and diarrhea

Acute GVH

Immunosuppressive therapy 1.
  

Allogenic transplantation always require immunosuppressive therapy Most of the drugs available are nonspecific Common side effects of therapy:
  

Infection Cancer Bone-marrow depression

Immunosuppression 2.


Conventional drugs (1st phase)

Steroids /Prednisone/ (0.1-10 mg / kg) Azathioprine /Imuran/ (0.5-3 mg/ kg) Cyclophosphamide (0.5-20 mg/ kg) Methotrexate (0.1-0.3 mg/ kg)

Immunosuppression 3.


New drugs (1):

  

CYCLOSPORIN A (=REVOLUTION !) 2-8 mg/ kg FK506 tacrolimus /PROGRAF/ Sirolimus - rapamycin Gusperimus - dezoxyspergualin

Effects of cyclosporins


Receptor: cytoplasmic immunophillin calcineurin blockage NF-Atc Rapamycin also binds to immunophillin, but the complex does not block calcineurin, it blocks proliferation in G1 phase.
Highly lymphocyte specific. IL-2 action is impaired. T lymphocyte (Th) is blocked.

 

Immunosuppression 4.


Purin antagonists
  

IMURAN CELLCEPT (micophenolate mofetil) Mizoribin bredinin

Pirimidin antagonists


Sodium-brequinar (highly lymphocyte

Monoclonal antibodies


OKT3 (Anti CD3 mAb)

CD3 T cells Activated T lymphocytes

Anti-TAC (anti-IL2 receptor)

  

Anti-CD4 Anti-LFA1 + anti-ICAM-1 experimental Anti-cytokine (IL-2, TNF , IFN )

Problems of Transplantation


There are not enough organs

 

At least 150,000 patients in industrially developed countries badly need donor organs and tissues Every 14 minutes another name is added to the national transplant waiting list. About 16 people die because of the lack of available organs for transplant each day. When the immune system of the host detects foreign graft tissue, it launches an attack, resulting in tissue rejection

Rejection:


Gene technology may as a solution

Lack of organs is no longer a problem technology makes it possible to humanize the bred organs - the immune system identifies the organ as its own tissue. Immune system rejection is prevented
Gene

From which animals are we able to transplant organs

1. The Chimpanzee: Its DNA sequence differs from ours by only 2%

2. The Baboon: Its organs are too small for a large adult human

3. The Pig: Surprisingly similar to our anatomy and physiology

Organ breeding: A transgenic animal carries a foreign gene inserted into its genome. The transgenic animal shows the specific characteristics which are coded on the inserted gene A gene which is responsible for the construction of a human organ makes the organism produce the organ additionally.

The insert of a foreign gene into an animal

II. Retrovirus gene transfer

Suppression of immune system rejection

  

The genes which are responsible for the own tissue not being rejected can be injected into an animal embryo the organs of which are then similar to the ones of the human. It is possible to humanize the bred organs by making certain genetic modifications. Then the organs are accepted by the immune system.

Conclusion


Transplantation provides us the means of restoring the function of a nonfunctional organ. In the case of BMT it enables us to administer such high doses of chemotherapy that would destroy the BM as well as the residual tumor. A lot immunologic knowledge had to be collected to understand what is happening.

Conclusion
 

 

HLA typing and matching is essential for allografting transplantation. Effective immunosuppressive therapy (Cyclosporin) revolutionised organ transplantation. The future is to transplant cells, that would restore the function of the affected organ. Gene therapy is growing, and will cause another revolution like cyclosporin did in the 1980s.

To seek what everybody has sought To think what nobody has thought Try your best, everything will be possible