Organ failure results in major human morbidity and economic burden. Quality of life and life expectancy are optimised with organ transplantation, usually occurring across histocompatibility barriers. The molecular mechanisms of graft rejection are based on recognition of foreign transplanted cells or tissues by the expression of polymorphic, codominant genes coded by the major histocompatibility complex (MHC) of human leukocyte antigens (HLA) or genes on chromosome 6 by recipient T cells and by the generation of donor‐specific antibodies to HLA and other donor‐specific immunogenic antigens. Advances in histocompatibility and immunosuppression have improved short‐term graft and patient survival rates, but rates of accelerated graft loss due to humoral alloimmunity have remained largely unchanged.
Key Concepts
In the ‘direct’ pathway of antigen presentation, MHC molecules on donor APCs from the graft tissue present graft‐derived peptides to host T cells.
In the ‘indirect’ pathway of antigen presentation, host APCs take up graft antigens and present donor‐derived processed peptides on host MHC molecules to host T cells.
HLA antibodies and endothelial cell activation are important regulators of immunogenicity, recruiting leukocytes to the site of inflammation.
Acute rejection can be classified by presentation into hyperacute (occurring within minutes), acute (occurring within days to weeks), late acute (occurring after 3 months) or chronic (occurring months to years after transplantation).
Acute rejection can be classified according to pathophysiological changes (cellular‐interstitial, vascular, antibody‐endothelial) or underlying immunologic mechanisms (adaptive or innate immune injury) or severity (histologic injury graded by the Banff schema).
Acute rejection can be clinical or subclinical (based on the presence or absence of associated renal dysfunction).
Acute rejection can be treatment resistant or sensitive (based on clinical and histologic resolution of diagnostic histology 4–6 weeks after treatment intensification).