Acquired immune tolerance to cadaveric renal allografts. A study of three patients treated with total lymphoid irradiation

Mutual tolerance after liver and not after heart transplantation? Evaluation of patient-anti-donor and donor-anti-patient responses by mixed lymphocyte culture

The ultimate goal in organ transplantation is the induction of donor-specific transplantation tolerance. The fact that in some patients it is possible to withdraw immunosuppressive therapy completely, suggests that immunological adaptation or donor-specific nonresponsiveness can occur following transplantation. In earlier studies we have shown that after blood transfusion, the mixed lymphocyte reactivity of the donor against patient peripheral blood mononuclear lymphocytes taken after blood transfusion gradually decreased with time. This may reflect the induction of an immunoregulatory mechanism, which protects the recipient against an immune reaction of the donor, enhancing a state of mixed chimerism. A similar phenomenon might also play a role in the immunological mechanism leading to transplantation tolerance. Therefore, we studied responses in patients with a well-functioning liver and heart transplant using a primed lymphocyte test (PLT) and a mixed lymphocyte culture (MLC). Two years after liver transplantation the PLT and MLC responses of patient against donor were decreased significantly compared to the situation before transplantation. The response of donor against patient was also lower two years after transplantation. The decreased responses were donor-specific since responses to third-party cells generally remained unchanged. In heart transplant recipients we could not detect a donor-specific downregulation. The reversed response, of donor against patient, was not different from responses of third-party against patient cells. Therefore, we conclude that donor-specific nonresponsiveness is not induced in patients with well-functioning heart transplants. In contrast, after a successful liver transplantation the response of patient against donor is decreased, as is the reversed response. It may be valuable to test whether in liver transplant patients withdrawing or reducing of maintenance immunosuppression is permitted for patients who appear to have developed two-way donor-specific hyporeactivity.

Association between enhanced Th2/Th1 cytokine profile and donor T-cell chimerism following total lymphoid irradiation

Total lymphoid irradiated (TLI) mice develop antigen specific tolerance if the initial antigen exposure occurs shortly after the completion of TLI. We injected TLI-treated mice with semiallogeneic donor cells at 2, 7, or 28 days after completing TLI and determined the levels of donor CD4 and CD8 cells 5 to 7 weeks after TLI treatment. The level of chimerism correlated with the timing of the initial alloantigen exposure. Donor CD4 and CD8 cells were noted only in day 2 or 7 injected mice. Because donor cell chimerism suggested increased in vivo survival of donor cells, we used the level of donor cell chimerism as a surrogate marker for tolerance to examine the relationship between the development of tolerance and enhanced Th2/Th1 cytokine responses to donor antigen. Increased levels of donor CD4 and CD8 cells in the TLI-treated mice was associated with increased Th2/Th1 cytokine production and decreased CTL activity to donor antigen in vitro. Higher Th2/Th1 cytokine levels also correlated with lower CTL activity. The results indicate that the increased production of Th2/Th1 may function to enhance survival of donor cells in TLI-treated mice and suggest that tolerance induction after TLI treatment involves immunoredirection.

Recipient preconditioning and donor-specific bone marrow infusion in a pig model of total bowel transplantation

BACKGROUND

In an outbred pig model of total bowel transplantation, we previously showed that simultaneous donor-specific bone marrow infusion (DSBMI), rather than promoting engraftment, sensitizes recipients and causes rejection; it also aggravates the risk of generalized graft-versus-host disease (GVHD) and infection, and tends to reduce recipient and graft survival. Small and large animal models of bone marrow-induced transplant tolerance suggest that some form of recipient preconditioning (RPC) may facilitate engraftment of co-transplanted bone marrow cells and fully expose their tolerogenic potential.

METHODS

In a preclinical model, we prospectively studied the effect of RPC on simultaneous DSBMI and total (i.e., small and large) bowel transplantation. RPC consisted of whole body irradiation with 400 R (day 0); some recipients additionally received horse anti-pig antithymocyte globulin (days -2, -1, and 0). We studied six groups of outbred pigs, all of which underwent at least a total bowel transplant: group 1, nonimmunosuppressed control pigs (n=5); group 2, nonimmunosuppressed DSBMI pigs (n=13); group 3, tacrolimus pigs (n=7); group 4, DSBMI+tacrolimus pigs (n=15); group 5, RPC+nonimmunosuppressed DSBMI pigs (n=11); and group 6, RPC+DSBMI+tacrolimus pigs (n=14).

RESULTS

RPC did not prolong overall survival at 7, 14, 21, and 28 days after transplant. Survival rates were 100%, 100%, 86%, and 71% in group 3; 71%, 43%, 29%, and 29% in group 6; 55%, 9%, 0%, and 0% in group 5; and 60%, 0%, 0%, and 0% in Group 1. Moreover, RPC (groups 5 and 6) increased the incidence of death from rejection, GVHD, and infection when compared with group 3. Survival was significantly higher for RPC+DSBMI+tacrolimus pigs (group 6), compared with RPC+nonimmunosuppressed DSBMI pigs (group 5). Survival greater than 28 days was noted only in pigs that received tacrolimus after transplant: 71% in group 3 versus 29% in group 6. With both RPC and DSBMI (groups 5 and 6), rejection, GVHD, and infection were not mutually exclusive events. In groups 5 and 6, at autopsy, the incidence of rejection and GVHD was 17%; rejection and infection, 17%; and GVHD and infection, 45%. A combination of all three immunologic events was noted in 14%.

CONCLUSIONS

RPC, combined with DSBMI, and with or without posttransplant immunosuppression, does not prolong survival after total bowel transplantation. Rather, it increases the incidence of death from rejection, GVHD, infection, or a combination of these three immunologic events. According to this preclinical study, RPC and unmodified DSBMI do not improve patient and graft outcome after total bowel transplantation and need to be refined before being applied clinically.

Donor-specific unmodified bone marrow transfusion does not facilitate intestinal engraftment after bowel transplantation in a porcine model

BACKGROUND

The immunosuppression required to prevent rejection of intestinal transplants causes a high rate of infection and lymphoma. It is crucial that immunomodulatory strategies be developed to facilitate intestinal engraftment.

METHODS

We prospectively examined the effect of unpurified donor-specific bone marrow transfusions (DSBMTs) on rejection, infection, graft-versus-host disease (GVHD), and survival after intestinal transplantations in 44 Yorkshire Landrace pigs. Four groups that differed according to presence or abscence of treatment with FK506 and DSBMT were analyzed.

RESULTS

In nonimmunosuppressed pigs, DSBMTs had no effect on survival (8 days versus 9 days in controls; p = 0.9). In FK506 pigs, DSBMTs tended to reduce survival (21 days versus 37 days in FK506 controls; p = 0.1); no difference was seen between two bone marrow dosages 5 x 10(7) or 5 x 10(8) bone marrow cells/kg. No difference in the incidence of death caused by rejection was seen between DSBMTs and controls, but there was a marked tendency toward more deaths caused by rejection in DSBMTs + FK506 versus FK506-only pigs (p = 0.09). Daily stomal assessment showed a higher rate of moderate and severe interstitial rejection in DSBMT + FK506 versus FK506-only pigs; DSBMT was also associated with increased vascular rejection. Finally, groupwise comparison showed an order of susceptibility to lethal GVHD and infection as follows: DSBMT + FK506 > FK506 > DSBMT > controls.

CONCLUSIONS

Rather than promoting engraftment, DSBMT can sensitize recipients and cause rejection after intestinal transplantation. It aggravates the risks of generalized GVHD and infection and tends to reduce graft and recipient survival. Before being applied clinically, DSBMT needs to be refined to increase its tolerogenic potential without causing GVHD.

Local graft irradiation after failure of modern immunosuppression in acute cellular and vascular graft rejection

PURPOSE

With improved chemical immunosuppressive agents, approximately 90% of rejection episodes can be reversed. However, in situations of failed immunosuppression, graft loss becomes inevitable. Our objective is to assess the efficacy of local graft irradiation (LGI) as an effort of last resort in a contemporary group of patients in whom graft failure to irreversible cellular and vascular rejection is imminent.

METHODS AND MATERIALS

A total of 308 renal transplantations were performed at our institution from 1992 to 1995, and an overall 1-year graft survival rate of 90% has been seen as a result of improvement in chemical immunosuppression. However, 6 patients were referred for LGI when all other measures failed to reverse the rejection crisis. Parameters that were studied in these patients included graft function and postirradiation graft histology.

RESULTS

Irradiation was associated with reversal of the rejection crisis and resulted in documented histological long-term graft survival in 1 of the 6 patients (17%). Two of the six patients (33%) had reversal of the rejection episode based on postirradiation biopsy of the renal allograft. Three of the six patients showed some level of clinical improvement of graft function for varying periods of time. One patient maintained stable allograft function without deterioration and with continued independence from hemodialysis. One recipient died from sepsis despite histologic improvement after irradiation.

CONCLUSIONS

Our impression is that LGI is indicated when all other measures have failed to reverse an acute rejection episode in the transplanted renal allograft. The role of radiation in this setting should be studied further.

Rejection of discordant neovascularized xenografts: is it similar to the response against metazoan parasites?

Allotransplantation is now widely successful but is increasingly limited by a shortage of human organ donors. Xenografts could solve this shortage but hyperacute rejection due to preformed antibodies that react with graft endothelial cells in primarily vascularized xenografts that cannot be controlled with current immunosuppressants causes graft loss and negates this approach. In the absence of hyperacute rejection, the host mounts a vigorous cellular response but its nature is poorly understood. In contrast, the cellular immune response against allografts is usually reversible with immunosuppression. The anti-xenograft response is similar to that generated against metazoan parasites but they often survive. Perhaps the host perceives a xenograft in a manner similar to the recognition of a parasite and reacts in a similar way but with parasites the response is often inadequate. Perhaps there are lessons to be learnt from parasitology that may be applicable to xenotransplantation.

Mechanisms of tolerance to rat heart allografts using posttransplant TLI. Changes in cytokine expression

Lewis rats were rendered tolerant to ACI heart allografts using a regimen of posttransplant total lymphoid irradiation (TLI), rabbit antithymocyte or antilymphocyte globulin (RATG or RALG), and a single donor blood transfusion. All three treatment modalities were required to induce tolerance. The mechanism of the maintenance of tolerance was investigated by comparing the secretion of cytokines in the MLR, and the expression of cytokine mRNA in the allografts of tolerant and nontolerant Lewis rats. Although, the 3H-thymidine incorporation and secretion of IL-2 was frequently comparable in the MLR from tolerant and nontolerant rats, the secretion of IFN-gamma was markedly reduced in the tolerant rats. This was reflected in a markedly reduced frequency of cells expressing IFN-gamma mRNA in the allografts of tolerant as compared with nontolerant hosts. The frequency of cells expressing IL-2 and IL-10 mRNA was also reduced, but no significant difference was observed for cells with IL-4 mRNA. Spleen cells from nontolerant rats rapidly rejected ACI allografts in irradiated adoptive hosts, but spleen cells from tolerant rats did not. Evaluation of the cytokine mRNA expression at early and late time points in the allografts of adoptive hosts showed a pattern similar to that of the primary hosts. Thus, the tolerant state was associated with a maintenance or elevation of IL-4 expression and a marked reduction of IFN-gamma expression. Previous reports have shown that TLI alone induced this shift in the early recovery phase after irradiation.

Complete withdrawal of immunosuppression in allograft recipients. A study in rhesus monkeys

The influence of pretransplant blood transfusions on kidney allograft survival after cessation of immunosuppressive treatment was studied in 11 rhesus monkeys. The animals were conditioned by three pretransplant blood transfusions. After an induction treatment with cyclosporine (CsA), the immunosuppression was stopped and the natural course of the graft was followed. In two monkeys long-term graft survival without immunosuppression was obtained (2.5 and 4.25 years). In a third monkey, permanent allograft acceptance was achieved after complete cessation of immunosuppression. The monkey is still alive with a well-functioning graft for more than 13 years after cessation of immunosuppression. This monkey had received CsA for 12 months, two MHC DR-matched blood transfusions, and no repeated mismatches between graft and blood transfusion donors. We speculate that blood transfusions may influence allograft function in two opposite ways. As reported previously in man, MHC class-II-matched transfusions appear to beneficially influence allograft survival. This effect seems to be negated by a mismatched MHC class II antigen in the blood transfusion donor which is also present in the organ donor -- a so-called repeated mismatch. Further studies in rhesus monkeys are required to confirm and extend these results. In the future, these observations might help in developing a protocol that opens up the possibility of cessation of immunosuppression in transplant patients.

Comparison of T cell responses in patients with a long-term surviving renal allograft versus a long-term surviving liver allograft. It's a different world

The aim of the present study was to analyze whether acquired transplantation tolerance had developed in patients with a long-term surviving renal or liver allograft. Analysis of antidonor cytotoxic T cell precursor frequencies was performed in 31 renal allograft recipients and 9 liver allograft recipients with good graft function 2 years after transplantation. The results demonstrated that, before transplantation, normal antidonor T cell responses were generated in both groups of patients. Two years after transplantation, donor-specific CTL nonresponsiveness had developed in a minority of the renal transplant recipients. In contrast, 8 out of 9 liver transplant recipients showed donor-specific mixed lymphocyte culture and CTL nonresponsiveness. These findings indicate that development of donor-specific T cell nonresponsiveness is not a common event after kidney transplantation, whereas liver transplantation seems to induce, at least in vitro, a state of donor-specific T cell nonresponsiveness.

[Immunologic tolerance after experimental liver transplantation]

Allografts in the rat liver are rejected less vigorously than other primarily vascularized allografts; they show a better survival rate and induce donor-specific unresponsiveness or tolerance in some donor-recipient combinations. This overview focuses on the immunologic mechanisms of this privileged status of liver allografts. A variety of possible mechanisms, such as generation of suppressor T-cells, humoral factors and microchimerism, has been related to the observed hyporeactivity. A further analysis of these phenomena may enhance the development of clinical organ transplantation protocols that allow for establishment of donor-specific unresponsiveness without the need for life-long immunosuppression.

Specific immune tolerance related to disparity in MHC class I region

A specific immune tolerance in mature, immunologically competent individuals may be induced by incompatibility for some of the class I major histocompatibility complex (MHC) antigens. This is suggested by results of experimental and clinical studies of organ transplantation and of antibody production. These results indicate the existence of tolerance-promoting allogenic markers within the MHC class I region.

Correlation of donor antigen-specific hyporeactivity with allogeneic microchimerism in kidney and lung recipients

Our previous studies indicate donor antigen-specific hyporeactivity is a useful marker for identifying solid organ transplant recipients at low risk for immunological complications; the hyporeactive subgroup experiences a lower incidence of chronic rejection. One purpose of the current study was to determine whether hyporeactivity could be identified in pediatric kidney recipients and whether it correlated with improved graft outcome. Of 18 pediatric kidney recipients tested, 6 (33%) had developed donor antigen-specific hyporeactivity. All 18 experienced good graft outcome. Second, we determined whether donor antigen-specific hyporeactivity correlates with peripheral blood microchimerism and outcome in adult kidney recipients. Our previous studies of lung recipients demonstrated development of obliterative bronchiolitis in recipients with microchimerism who remain responsive, but not in recipients who had become hyporesponsive to donor antigen. Preliminary results in our current study of 23 adult kidney recipients indicate microchimerism for 6 (26%): 4 hyporesponsive and 2 responsive to donor antigen. Microchimerism was not detected for 17 recipients: 6 hyporesponsive and 11 responsive to donor antigen. One hyporesponsive/chimeric patient and 4 recipients negative for both parameters have been diagnosed with biopsy-proven chronic rejection. In summary, both hyporeactivity and chimerism are found at a higher frequency in lung than kidney recipients. Unlike lung recipients, not all hyporesponsive kidney recipients had peripheral blood chimerism. Additional numbers are needed to determine if microchimerism correlates with donor antigen-specific hyporeactivity or graft outcome.

Peripheral tolerance to alloantigen: strategies for the future

The mature, adult immune system is specifically designed to eliminate any foreign material that may enter the body, but not to respond to the body's own tissues and molecules. Indeed, during development, the potential of the immune system to respond to self antigens is removed, by eliminating or effectively silencing any autoreactive cells. These features are well adapted under normal circumstances, as they result in the efficient elimination of potentially harmful agents thereby protecting the body from infection and malignancy. However, in the context of transplantation, this 'normal' response is diametrically opposed to the desired clinical outcome, which is clearly the long term function and survival of the transplanted tissue. To prevent graft rejection the immune system of the transplant recipient has to be manipulated to ensure that it is incapacitated. Immunosuppressive drugs can be used for this purpose and are undoubtedly effective; indeed they have had a dramatic impact on success rates in clinical organ transplantation. However, as the mechanism of action of these chemical immunosuppressants is immunologically non-specific, any immune response the recipient may need to make after transplantation, as well as the rejection response, is suppressed. In addition, to maintain graft survival the drugs have to be taken indefinitely after transplantation and therefore their use is not only associated with immunological complications such as increased risks of infection and malignancy, but also numerous non-immunological side-effects. One way to overcome these problems would be to develop strategies for specific immunosuppression, such that only leukocytes capable of responding to the foreign histocompatibility or alloantigens expressed by the transplanted tissue would be affected. The ability to manipulate or reprogramme the adult immune system in such a way as to induce specific immunological unresponsiveness or tolerance to the alloantigens of the organ donor would offer many advantages over conventional immunosuppressive therapy. Only leukocytes reactive with donor alloantigens would be affected, thus allowing transplant recipients to respond effectively to other immunological stimuli, such as virus infections.

Donor cell chimerism permitted by immunosuppressive drugs: a new view of organ transplantation

One line of thought in organ transplantation feels that immunosuppressive drugs can lead to tolerance induction by allowing a previously unrecognized common mechanism of cell migration and microchimerism to occur, persist, and in some cases, become drug independent. It has been recognized that there is a spectrum of susceptibility of different organs to cellular rejection and that the variable ability of these organs to induce donor-specific nonreactivity reflects their comparative content of migratory leukocytes. Here, Thomas Starzl and colleagues discuss how many of the enigmas of transplantation immunology can be explained by this chimerism.

Cell migration and chimerism after whole-organ transplantation: the basis of graft acceptance

Improvements in the prevention or control of rejection of the kidney and liver have been largely interchangeable (1, 2) and then applicable, with very little modification, to thoracic and other organs. However, the mechanism by which anti rejection treatment permits any of these grafts to be “accepted” has been an immunological enigma (3, 4). We have proposed recently that the exchange of migratory leukocytes between the transplant and the recipient with consequent long-term cellular chimerism in both is the basis for acceptance of all whole-organ allografts and xenografts (5). Although such chimerism was demonstrated only a few months ago, the observations have increased our insight into transplantation immunology and have encouraged the development of alternative therapeutic strategies (6).

Donor cell chimerism permitted by immunosuppressive drugs: a new view of organ transplantation

One line of thought in organ transplantation feels that immunosuppressive drugs can lead to tolerance induction by allowing a previously unrecognized common mechanism of cell migration and microchimerism to occur, persist, and in some cases, become drug independent. It has been recognized that there is a spectrum of susceptibility of different organs to cellular rejection and that the variable ability of these organs to induce donor-specific nonreactivity reflects their comparative content of migratory leukocytes. Here, Thomas Starzl and colleagues discuss how many of the enigmas of transplantation immunology can be explained by this chimerism.

Molecular monitoring of the immunosuppressive effects of cyclosporine in renal transplant patients by using a quantitative polymerase chain reaction

We have developed a rapid (24 hours) quantitative PCR assay to measure the direct effect of cyclosporine on IL-2 mRNA production by activated PBMC cultures from renal transplant patients. The PBMCs were purified from normal laboratory volunteers (group A, n = 26), CsA-treated renal transplant patients with good renal function, tested between 3 and 8 weeks (group B, n = 14) or between 2 and 8 years (group C, n = 15) after surgery, and stimulated with PHA in media supplemented with either patient serum or pooled commercially obtained AB serum. The mRNA was then isolated and, using semiquantitative PCR or quantitative PCR with a competitive inhibitor, the relative levels or exact levels of IL-2 mRNA (in attomoles) could be measured. A 3-day confirmatory lymphoproliferation assay of [3H]thymidine incorporation was also performed on the samples. Kinetic analysis of the data from group A showed that the peak level of IL-2 transcription into mRNA occurred at 6 hours after mitogen stimulation. Increasing in vitro concentrations of CsA in this group resulted in lower IL-2 mRNA levels and a shift in the peak time to 12-24 hours. In the transplant recipients, there was no correlation between individual CsA blood levels and proliferation responses. However, some correlation was found between CsA blood levels and IL-2 mRNA levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Future directions in transplantation

Transplantation has become an established treatment for many diseases where organ replacement is the best or perhaps the only option, but it has not reached its full potential. The use of fetal and infant donors raises ethical problems, as does the use of other species for xenografts. Legal problems include the drafting of appropriate legislation to maximise the donor pool. Economic limitations are imposed by the competition for funding with other areas of medicine. Transplantation of cells, tissues, and organs is rapidly being expanded. Exciting progress in experimental models of new methods of immunosuppression may lead to immunological tolerance of grafts so that chronic non-specific immunosuppression becomes a thing of the past. Xenografts will probably have to become a major source of organs as transplantation is extended to more patients and a broader range of diseases. Genetic engineering may alleviate the problem of supply in some instances; free cell transplants of genetically modified cells are being studied.

Perspectives in transplantation immunology 1991

The clinical success of organ transplantation depends to a large degree on the immunological acceptance of the grafted organ. This paper summarizes from an immunological point of view the recent progress that has been made to improve graft acceptance, and discusses some future aspects in the field. Over the last few years, major emphasis has been put on the development of new immunosuppressive drugs, including FK 506, rapamycin, and Deoxyspergualin. Together with monoclonal antibodies against defined T-cell surface antigens, there are now new and effective means available to prevent or treat rejection episodes. Progress has also been made in the field of HLA typing, where the introduction of molecular biology-based methods significantly increased the accuracy of HLA class II typing. The ultimate goal of transplantation immunology is the induction of (donor-) specific tolerance. While some protocols are effective in inducing peripheral tolerance in experimental animals, these regimens are at present not yet applicable in the clinical situation. To overcome the shortage of donor organs, alternative strategies are currently being considered. Among these, xenotransplantation may eventually prove successful, despite the massive immunological problems such as, e.g., the presence of preformed xenoreactive antibodies.

Alternative approaches for the induction of transplantation tolerance

The immunosuppressive drugs currently in use in clinical transplantation are undoubtedly very effective at controlling graft rejection. However, their use is associated with a large number of side-effects, both immunological and non-immunological, particularly in the longer term. From an immunological point of view, the major disadvantage of these agents is that their mode of action is immunologically non-specific, resulting in blanket or pan-immunosuppression of the recipient's immune system. Thus, not only is the recipient's immune response against the organ graft suppressed, but responses to all other antigenic stimuli such as viral infections are also prevented. The transplant recipient can therefore become severely immunocompromised as a result of the drug therapy and is susceptible to opportunistic infections and an increased incidence of cancer. One of the aims for the design of new immunosuppressive therapy is to develop protocols that are both effective and immunologically specific, such that only the immune response to the transplanted organ is suppressed. The optimal approach would be to induce tolerance to the donor histocompatibility antigens before transplantation, permanently paralysing the ability of the recipient's immune system to mount a rejection response against the graft. Some of the approaches for the induction of immunological tolerance currently being explored in clinical transplantation will be discussed. These include total lymphoid irradiation (TLI) and donor bone marrow transfusion combined with anti-lymphocyte globulin (ALG) post-transplantation. In addition some new approaches for the induction of tolerance before transplantation currently being investigated in experimental systems will be presented.

Mechanism, pathophysiology, diagnosis, and management of renal transplant rejection

In recent years, there has been a steady progress in basic research (immunogenetics and cellular immunology) that helped us in understanding the mechanisms underlying allograft rejection. Several laboratory tests were developed, and the results were shown to correlate with clinical rejection. However, most of these studies have not found a place in clinical practice because of their nonspecificity, lack of sensitivity, time lag, added expense, and inconvenience. The commonly employed diagnostic tests (i.e., renal transplant ultrasound and 131I hippuran scintigram) are helpful in differentiating rejection from other causes of graft malfunction. The specific renal parenchymal disease, such as acute or chronic rejection or de novo or recurrent glomerular disease, contributing to graft malfunction can only be diagnosed by renal histopathologic study. Because hyperacute and accelerated acute rejections are irreversible and necessitate graft nephrectomy, measures should be taken to prevent this problem. High-dose corticosteroids still remain the mainstay of therapy for acute cellular rejection. In the case of steroid-resistant rejections, treatment with ALG or OKT3 appears promising. As there is no effective therapy for chronic allograft rejection, usual measures of delaying the progression of chronic renal failure should be employed, and patients should be advised to return to maintenance dialysis before they develop uremic symptoms. If current experiments demonstrating selective immunosuppression with monoclonal antibodies are found successful in human trials, one can expect further improvement in the outcome of renal transplantation.

The influence of allogeneic cells on the human T and B cell repertoire

Clinical transplantation is often complicated by rejection episodes, in which the immune system of the recipient reacts to the foreign transplantation (HLA) antigens on the graft. This immune response includes humoral and cellular components. In the first, B lymphocytes form antibodies to the HLA alloantigens. In the second, CD8+ T lymphocytes recognize and react to HLA class I antigens, and CD4+ T cells react to HLA class II antigens. The frequency and severity of these rejection episodes can be diminished by immunosuppressive drugs, HLA matching between donor and recipient, and immune modulation by blood transfusion. Effective HLA matching between donor and recipient is not always possible and often not necessary. Insight into the factors that influence the T and B cell repertoire after blood transfusion might lead to new approaches to improve graft survival.