Core Curriculum in Nephrology

Transplant Immunology and Immunosuppression:

Core Curriculum 2015
Donald E. Hricik, MD

K idney transplantation is the kidney replacement

therapy of choice for patients with kidney failure
as long as there are no comorbid conditions that pre-
antigen-presenting cells (APCs), soluble mediators
such as cytokines, and effector cells that target and
injure the transplant. It is useful to consider the
clude the surgery or interfere with the ability to adhere cellular and noncellular components of alloimmunity
to long-term immunosuppression. In acceptable candi- (Box 2) when attempting to understand the effects and
dates, kidney transplantation is more cost-effective than limitations of current therapeutics in transplantation.
dialysis and is associated with lower mortality rates than
those observed in waitlisted individuals. During the past Allorecognition
3 decades, kidney transplant recipients have benefitted The major histocompatibility complex (MHC)
from remarkable improvements in short-term outcomes comprises cell-surface proteins encoded by a gene
compared with recipients in earlier eras. Specifically, family located on chromosome 6. The primary
1-year kidney transplant survival rates are now w95%, immunologic role of MHC gene products is to present
and the incidence of acute rejection during the first year antigens—in the form of fragments of foreign
after transplantation is now w15%. Long-term out- proteins—so that they can be recognized by T lym-
comes have improved much less impressively. Alloim- phocytes through their antigen-specific receptors.
mune reactions resulting in acute and/or chronic MHC molecules are required for presentation of
rejection remain the primary barrier to long-term sur- foreign antigens because T cells are not capable of
vival of the kidney transplant. Immunologic tolerance responding to soluble proteins.
can be achieved with relative ease in small animals. Antigen presentation begins with binding of a
However, the human immune system is complex, con- peptide antigen by MHC (Fig 1). MHC molecules are
taining redundant pathways that make tolerance difficult composed of one highly polymorphic polypeptide
to achieve. Thus, in the current era, transplant rejection a chain and a monomorphic b chain, consisting of
still constitutes the major threat to long-term survival of b2-microglobulin in the case of class I MHC. Allo-
transplanted kidneys, and nearly all transplant recipients specificity of class I MHC molecules, constitutively
require life-long treatment with immunosuppression to expressed on all nucleated cells, resides in the
mollify alloimmune responses and allow for long-term a chain, a polypeptide with a prominent groove or
transplant survival. This review focuses on immune pocket in which foreign peptides bind for presentation
mechanisms of kidney transplant injury and treatments to T cells. Class II MHC molecules are constitutively
currently used to prevent or treat transplant rejection expressed only on APCs, including dendritic cells,
(see Box 1 for outline of topics).

MECHANISMS OF TRANSPLANT REJECTION Box 1. Overview of Transplant Immunology and

Immunosuppression
The main responsibility of the immune response is
to defend against infectious pathogens, a role that  Mechanisms of transplant rejection
requires both recognition of pathogens and subse-  Allorecognition
 T-cell activation and differentiation
quent activation of immune cells and soluble media-  Effector mechanisms
tors of immunity. Similarly, the immune responses  Role of B cells
that lead to recognition and destruction of a transplant  Types of rejection
require mononuclear cells with migration capacity,  Hyperacute rejection
 Acute cellular rejection
 Acute humoral rejection
 Chronic rejection
From the Department of Medicine, University Hospitals Case  Prevention of rejection
Medical Center, Cleveland, OH.  Desensitization protocols
Received October 6, 2014. Accepted in revised form January  Induction therapy
15, 2015. Originally published online April 21, 2015.  Maintenance immunosuppression
Address correspondence to Donald E. Hricik, MD, University  Treatment of rejection
Hospitals Case Medical Center, 11100 Euclid Ave, Cleveland,  Acute cellular rejection
OH 44106. E-mail: [email protected].  Acute humoral rejection
Ó 2015 by the National Kidney Foundation, Inc.  Chronic rejection
0272-6386  Strategies for achieving tolerance
http://dx.doi.org/10.1053/j.ajkd.2015.01.026

956 Am J Kidney Dis. 2015;65(6):956-966

Core Curriculum in Nephrology

Box 2. Components of the Alloimmune Response processed by recipient APCs and presented to the
 Antigen (peptide) TCR. In the transplant, indirect allorecognition occurs
 Major histocompatibility complex (MHC) when recipient APCs process donor peptides and
 Antigen-presenting cells (APCs) engage recipient lymphocytes by presenting those
 T and B cells processed peptides. The direct pathway of allor-
 Costimulatory factors and cytokines
 Effector cells, inflammation, and injury
ecognition plays a dominant role in early T-cell–
mediated acute rejection episodes, whereas the indi-
rect pathway is believed to be more important in
macrophages, and B cells. For these molecules, mediating chronic rejection.
adjacent portions of the highly variable a chain and a
nonvariable b chain create the peptide groove. For T-Cell Activation and Differentiation
either class, the size of the grooves is too small to The TCR is a heterodimer that consists of 2 linked
bind large intact proteins. Thus, native proteins must polypeptide chains, a and b. The TCR is then linked
be processed into smaller fragments that can bind to to another group of cell-surface molecules known as
MHC molecules. The highly variable amino acid CD3, a complex that consists of at least 5 covalently
residues located in the groove determine the speci- bound peptide chains: g, d, ε, z, and h. When the
ficity of peptide binding and T-cell antigen recogni- TCR binds to an MHC-presented antigen, there is a
tion. Functionally, the same T-cell receptor (TCR) can conformational change in CD3 that activates intra-
recognize either class I or class II MHC molecules, cellular signal pathways, including tyrosine kinases
but restrictions are imposed by the engagement of the on the intracytoplasmic tails of the CD3 complex, as
T-cell surface molecules CD4 and CD8 to class II well as the CD4 and CD8 accessory molecules. This
and class I molecules, respectively (Fig 2A). Thus, antigen-driven signal that is transduced by the TCR-
CD4-positive T cells primarily engage peptides CD3 complex to the T-cell cytoplasm has been
presented by class II MHC, whereas CD8-positive T called “signal 1.” This signal is essential, but not
cells engage peptides presented by class I MHC. sufficient, for full activation of T cells.
Immediately following vascularization of a trans- A second antigen-independent signal (signal 2)
planted organ, donor antigens enter the systemic must be provided through additional accessory mol-
circulation and travel to the lymph nodes and spleen, ecules that costimulate the T cell. Although the family
where naive T cells become activated. At the same of known costimulatory ligands continues to grow,
time, recipient cells enter the transplant. Direct the most important are ligands between 2 T-cell sur-
allorecognition (Fig 2A) occurs in either the second- face molecules, B28 and CD154 (CD40 ligand), and
ary lymphoid system or the transplant. In the the APC surface molecules B7 and CD40, respec-
lymphoid system, this happens when the recipient’s tively (Fig 3). The provision of signals through the
naive lymphocytes are engaged with donor APCs that TCR alone (without costimulation) leads to clonal and
have traveled to the lymph nodes or spleen. In the antigen-specific anergy. The T cell does not produce
transplant, direct allorecognition occurs when donor cytokines or undergo cell division and it becomes
APCs engage with recipient lymphocytes. Indirect unresponsive to appropriate stimulation or apoptosis
allorecognition (Fig 2B) occurs in the secondary (undergoes programmed cell death).
lymphatic system when donor proteins or peptides are With adequate costimulation, T-cell activation
continues and signals are transduced to the nucleus. A
key step in activating T cells is phosphorylation of
proteins that form the signaling chain for gene tran-
scription. The immediate effect is phosphotyrosine
kinase–mediated phosphorylation of tyrosine residues
of several proteins. The phosphorylation modification
activates an enzyme that catalyzes the breakdown of
plasma membrane phospholipids and the generation
of the second messengers inositol 1,4,5 triphosphate
(IP3) and diacylglycerol (DAG). IP3 triggers the
release of ionized calcium from intracellular stores
Figure 1. Schematic of the peptide-binding pockets for class while DAG activates protein kinase C, leading to
II molecules derived from the DP, DQ, or DR loci of the major
histocompatibility complex of chromosome 6 and for class I mol- the synthesis of nuclear regulatory elements such as
ecules derived from the B, C, or A loci. Figure courtesy of Dr P. the proto-oncogenes c-fos and c-jun. Released cyto-
Heeger; adapted from Schröppel and Heeger (Transplantation plasmic calcium forms a complex with calmodulin, a
Immunology. In: Hricik DE, ed. Kidney Transplantation. 2nd
ed. London: Remedica, 2007:9-38) with permission of Remedica calcium-dependent regulatory protein. These calcium-
Medical Education and Publishing. calmodulin complexes activate other kinases and

Am J Kidney Dis. 2015;65(6):956-966 957

 Donald E. Hricik

Figure 2. (A) Depiction of direct

allorecognition in which a donor
antigen-presenting cell (APC) presents
peptide to the T-cell receptor (TCR)
within the context of donor major histo-
compatibility complex (MHC) molecule.
(Left side) Presentation of a peptide
within a class I MHC molecule to a
CD8-positive T cell. (Right side) Pre-
sentation of a peptide within a class II
MHC molecule to a CD4-positive T
cell. (B) Depiction of indirect allorecog-
nition in which an antigen is first pro-
cessed by a recipient APC and then
presented within the context of a recip-
ient MHC molecule to either a CD4- or
CD8-positive T cell. Figure courtesy of
P. Heeger.

phosphatases, including calcineurin. Calcineurin, a In contrast, T and B cells provide finely tuned
calcium-calmodulin complex–dependent phosphatase, specificity; however, developing this adaptive im-
plays a key role in the activation of factors required munity requires days to weeks. Although transplant
for interleukin 2 (IL-2) gene transcription. rejection requires T-cell activation, it is important to
The transcription of IL-2 and other cytokines ulti- recognize that other cells of the immune system can
mately drive cell-cycle progression (signal 3) and contribute to transplant injury. For example, endo-
proliferation (Fig 4) with help from a series of thelial cells participate in the maturation of dendritic
kinases, including members of the target of rapamycin cells. Mesangial cells in the kidney produce matrix
(TOR) pathway. The final result of activation is the that regulates immune responses. Tubular epithelial
proliferation of CD4-positive helper T (TH) cells and cells express TGFb and other cytokines that can
the maturation of CD8-positive cytotoxic T cells. contribute to fibrosis. The complement system
Activated T cells can ultimately differentiate into a serves as an important interface between innate and
number of other phenotypes, including memory cells, adaptive immunity. The terminal components of
which can respond quickly and robustly to the orig- complement are important effectors of transplant
inal antigen many years after it was first presented, destruction, leading to membrane injury, neutrophil
and regulatory cells (Tregs), which can suppress infiltration, and damage to epithelial and endothelial
immune responses and promote tolerance. cells. However, the complement system is also
Both CD4- and CD8-positive T cells can be involved in T- and B-cell stimulation.
divided into subsets defined by the cytokines they
produce following activation. The cytokines act as
potent biological response modifiers; thus, CD4-
positive TH cells may be of the TH1 subset (produc-
ing IL-2 and interferon g [IFN-g]) or the TH2 subset
(producing IL-4 and IL-5). The latter group of cyto-
kines is involved in B-cell help. Other subsets of T
cells express the cytokine transforming growth factor
b (TGFb).
Effector Mechanisms
Humans possess an innate immune system
designed to quickly stymie the spread of infectious
pathogens. Innate immunity (designed to destroy a
pathogen) is often initiated by Toll-like receptors,
modulated by complement activation, and mediated
by macrophages and natural killer cells. Recently
Figure 3. Depiction of 2 costimulatory signals, CD40:CD40
there has been interest in the concept that this ligand (CD40L) and B7:CD28, which are required for full T-cell
pathway may interact with alloimmune mechanisms, activation, beginning with presentation of a peptide by an
thus forming a potential link between nonspecific antigen-presenting cell (APC) to the T-cell receptor (TCR). The
B7 accessory molecule consists of either CD80 or CD86, which
injury (eg, ischemia-reperfusion injury or infections) binds to CD28 with different affinities. Abbreviation: MHC, major
and acute rejection. histocompatibility complex. Figure courtesy of P. Heeger.

958 Am J Kidney Dis. 2015;65(6):956-966

Core Curriculum in Nephrology

Differentiated plasma cells generate antitransplant

antibodies that can act by fixing complement or
opsonizing cells that are then killed by cell-
mediated lympholysis. B cells also serve as excel-
lent APCs.
Recently, alloantibodies have been re-identified as
major effectors of both acute and chronic transplant
injury. Alloantibodies are primarily directed against
HLA antigens. However, a number of less common
alloantibodies to non-HLA antigens (eg, endothelial
or epithelial antigens) have been identified and
occasionally cause transplant injury. Preformed anti-
bodies to HLA antigens most commonly occur in
patients who have had previous transplants, preg-
Figure 4. Schematic of the 3 signals required for full activa-
nancy, or blood transfusions. Less commonly, they
tion and proliferation of T cells and the sites of action for develop cross-reactively after exposure to vaccines,
commonly used maintenance immunosuppressive drugs. See viruses, or other pathogens. Preformed anti-HLA an-
text for details. Abbreviations: IL-2R, interleukin 2 receptor; tibodies are measured by a variety of cross-matching
MPA, mycophenolic acid; TCR, T cell receptor; TOR, target of
rapamycin. Figure courtesy of P. Heeger; adapted from Schröp- techniques beyond the scope of this review. Mixing
pel and Heeger (Transplantation Immunology. In: Hricik DE, ed. recipient serum with the cells or with HLA antigens
Kidney Transplantation. 2nd ed. London: Remedica, 2007:9-38) of a specific donor performs a donor-specific cross-
with permission of Remedica Medical Education and Publishing.
match. When the serum of a potential transplant
recipient is “cross-matched” with cells from a large
The Fas/Fas ligand (FasL) pathway is another panel of potential donors, the test is referred to as a
important effector mechanism. Fas is ubiquitously panel-reactive antibody (PRA) test. Patients with a
expressed on parenchymal cells, whereas FasL is high PRA score (ie, preformed anti-HLA antibodies
induced upon activation of CD4-positive T cells. against a large number of potential donors) are said to
Cross-linking of Fas with trimerized FasL ultimately be sensitized and generally exhibit transplant out-
activates caspase 8 and propagates a death signal that comes that are inferior to nonsensitized patients. In
ends in apoptosis. theory, only donor-specific antibodies (DSAs) are
Activation of caspase enzymes that eventually responsible for transplant injury. Transplantation is
lead to irreversible cell injury and death can also usually avoided in patients with pre-existing DSAs.
occur independently of cell-surface receptors. However, very low titers may escape detection by
CD8-positive T cells express cytotoxic molecules even the most sensitive of cross-matching techniques.
that are lethal to cells. One of these, granzyme B, Moreover, de novo DSAs develop in as many as 15%
requires a pore structure to gain access to the of kidney transplant recipients during the first year
cell. That pore is formed by perforin, another after transplantation and increase in frequency with
product of cytotoxic T cells, which is inserted into the passage of time; they are now recognized as a
the target cell membrane in a calcium-dependent major cause of late transplant injury and transplant
process. When granzyme B enters the target cell loss.
cytosol, it triggers pathways that result in cell death
through apoptosis. Natural killer cells are effector Additional Readings
cells that also produce perforin and granzyme B. In
» Cravedi P, Heeger PS. Complement as a multifaceted
addition, they produce IFN-g, thus promoting modulator of kidney transplant injury. J Clin Invest.
inflammation. 2014;124(6):2348-2354.
» Delves PJ, Roitt IM. The immune system. First of two parts.
Role of B Cells N Engl J Med. 2000;343(1):37-49.
With the help of TH2 T cells, bone marrow– » Delves PJ, Roitt IM. The immune system. Second of two
parts. N Engl J Med. 2000;343(2):108-117.
derived B cells can differentiate into plasma cells » Gebel HM, Bray RA, Nickerson P. Pre-transplant assessment
that ultimately produce antibodies specific for the of donor-reactive, HLA-specific antibodies in renal trans-
original peptide antigen presented to the T cell. plantation: contraindication vs. risk. Am J Transplant.
Recently, several growth factors necessary for this 2003;3(12):1488-1500.
differentiation have been identified and may » Gould DS, Auchincloss H Jr. Direct and indirect recognition:
the role of MHC antigens in graft rejection. Immunol Today.
ultimately serve as therapeutic targets. Mature B 1999;20(2):77-82.
cells are found mainly in lymphoid follicles and » Klein J, Sato A. The HLA system. First of two parts. N Engl J
bone marrow and in low numbers in the circulation. Med. 2000;343(10):702-709.

Am J Kidney Dis. 2015;65(6):956-966 959

 Donald E. Hricik

» Klein J, Sato A. The HLA system. Second of two parts. N Box 4. Banff 2007 Classification for Acute Kidney Transplant
Engl J Med. 2000;343(11):782-786. Rejection
» Li XC, Rothstein DM, Sayegh MH. Costimulatory pathways
Acute Cellular Rejection
in transplantation: challenges and new developments.
 “Borderline changes”: mild form of T-cell–mediated
Immunol Rev. 2009;229(1):271-293.
rejection with no intimal arteritis but minor interstitial in-
» Wolfe RA, Ashby VB, Milford EL, et al. Comparison of
flammation with foci of tubulitis
mortality in all patients on dialysis, patients on dialysis
 Grades
awaiting transplantation, and recipients of a first cadaveric
 Grade IA: Interstitial inflammation in at least 25% of
transplant. N Engl J Med. 1999;341(23):1725-1730.
parenchyma and moderate tubulitis
 Grade IB: Like IA but more extensive tubulitis
TYPES OF REJECTION  Grade IIA: Mild to moderate intimal arteritis
 Grade IIB: Severe intimal arteritis comprising at least
Transplant rejection can be classified based on 25% of luminal area
clinicopathologic criteria into hyperacute, acute, and  Grade III: Transmural arteritis
chronic forms (Box 3). Although acute forms of Acute Antibody-Mediated Rejection
rejection are usually divided into cellular and humoral  Requires positive C4d staining and the presence of
types, there are sometimes components of both circulating donor-specific antibodies with 1 of 3 histologic
cellular- and antibody-mediated damage in a single variants:
 An ATN-like picture
tissue specimen. The term chronic rejection was  Capillary involvement
considered obsolete a decade ago, but has made a  Arterial involvement
comeback with increasing recognition of the role of
antibodies in mediating immune damage (which was Based on Solez et al (Am J Transplant. 2008;8:753-760).
Abbreviation: ATN, acute tubular necrosis.
once encompassed under the broader term chronic
allograft nephropathy). The Banff criteria are histo-
logic criteria used to assess the type and severity of Hyperacute Rejection
rejection. Although the criteria have been revised This form of rejection occurs in recipients with high
often, traditionally they have been most useful in titers of preformed DSAs and is a rare occurrence in
assessing the severity of acute forms of kidney the era of modern highly sensitive cross-matching
transplant rejection (Box 4). Banff indexes for chronic techniques. Clinically, hyperacute rejection most
injury were historically more helpful in assessing the often presents immediately after revascularization of
severity of interstitial fibrosis and tubular atrophy. the transplant, with overt necrosis of the transplant
However, the criteria continue to be revised to allow before completion of the operation, usually mandating
grading of acute and chronic humoral rejection. immediate transplant nephrectomy. Delayed hyper-
Biopsy of the transplanted kidney remains the gold acute rejection, presumably reflecting lower DSA
standard for the diagnosis of rejection. Subclinical titers and less immediate destruction of the transplant,
rejection is found in 5% to 25% of protocol biopsies has been described, necessitating nephrectomy hours
performed during the first 6 posttransplantation to days after the initial operation. The histology of
months in patients with stable kidney function, an hyperacute rejection is characterized by fibrinoid
observation suggesting that immune injury can occur necrosis of arterioles, reflecting complement-mediated
before kidney function begins decreasing. This is one antibody damage to endothelial cells.
line of evidence that has fueled interest in developing Acute Cellular Rejection
immune biomarkers that can be used as surrogates for
invasive biopsies or as predictors of imminent rejec- Acute cellular rejection accounts for 90% of early
tion, to potentially allow therapeutic intervention rejection episodes (ie, those occurring in the first 3
before the immune injury affects transplant function. months posttransplantation) and is mediated by the
A number of promising urine biomarkers have been activation and proliferation of T cells. Use of induc-
reported in recent years, but have not yet achieved tion antibody therapy may delay the onset of cellular
widespread use in clinical practice. rejection. Moreover, lack of adherence to or inten-
tional withdrawal of maintenance immunosuppression
can result in acute cellular rejection even years after
Box 3. Types of Kidney Transplant Rejection transplantation. In the modern era, acute cellular
 Hyperacute
rejection is rarely symptomatic and most often is
 Acute cellular recognized by declining kidney function (ie, in-
 Interstitial creasing serum creatinine concentration or decreas-
 Vascular ing glomerular filtration rate). Histologically, it is
 Acute humoral characterized by interstitial inflammation (a mix-
 Mixed (features of both cellular and humoral)
 Chronic
ture of lymphocytes, macrophages, and occasional
eosinophils; Fig 5A and B), vascular inflammation

960 Am J Kidney Dis. 2015;65(6):956-966

Core Curriculum in Nephrology

Figure 5. (A) Low-power view of a

transplant kidney biopsy specimen
shows interstitial inflammation affecting
.25% of the core in a acute
cellular rejection (hematoxylin and eosin
stain). (B) High-power view of the same
specimen shows infiltration of the inter-
stitium with round cells and macro-
phages, and “tubulitis” characterized by
lymphocytic invasion of tubular base-
ment membranes and entrance into the
tubular lumen (arrows) (hematoxylin
and eosin stain).

(lymphocytic infiltration of vascular intima), or both. of interstitial fibrosis, tubular atrophy, and glomer-
Vascular involvement (Banff grade II) reflects a more ular changes characterized by the term transplant
severe variant than isolated interstitial disease (Banff glomerulopathy. The isolated findings of interstitial
grade I), as evidenced by a poorer response to therapy fibrosis/tubular atrophy (IFTA) have traditionally
and worse long-term transplant survival. Clinical been attributed to nonimmune mechanisms such as
factors associated with high rates of acute cellular hyperfiltration in a solitary kidney or the toxic
rejection include retransplantation, humoral sensiti- effects of calcineurin inhibitors (CNIs). The fibrotic
zation (PRA score . 50%), history of delayed graft effects of CNIs have been overplayed because recent
function, African American ethnicity, and treatment prospective studies of patients with isolated fibrosis
nonadherence. have demonstrated remarkably little adverse effect on
Acute Humoral Rejection long-term transplant survival. However, the presence
of inflammation (ie, inflammatory infiltrates not
Acute humoral rejection can occur early after meeting Banff criteria for acute rejection), with or
transplantation in highly sensitized patients (including without IFTA, appears to compromise long-term
those who have been treated with desensitization transplant survival and will be the focus of future
protocols) or any time after transplantation in patients interventional trials. Transplant glomerulopathy
who develop de novo DSAs. Symptoms are rare and occurs more commonly in patients with positive
patients usually present with either declining kidney staining for C4d and/or detectable DSAs and confers
function or an increase in urine protein excretion. The an ominous prognosis, with transplant survival rates
histologic hallmark of acute humoral rejection is far lower than those observed in patients with negative
peritubular capillaritis manifested by infiltration of study results.
these capillaries with lymphocytes and especially with Histologically, transplant glomerulopathy strongly
neutrophils (Fig 6). In severe cases, fibrinoid necrosis resembles idiopathic membranoproliferative glomer-
may be seen in peritubular capillaries and glomeruli. ulonephritis, complete with mesangial proliferation
C4d is a complement component that binds to renal
tissue after complement activation and thus represents
a sign of recent attack by complement-dependent
antibodies. The presence of C4d in peritubular cap-
illaries, detected either by standard immunofluores-
cence techniques or peroxidase staining, is highly
suggestive of acute humoral rejection (especially
when the staining is dense and linear) and is closely
associated with the presence of circulating DSAs.
However, the specificity of C4d positivity is subop-
timal. Histologic signs of humoral rejection in the
absence of C4d staining remain concerning, whereas
in the absence of histologic changes, the significance
of C4d staining (especially if patchy and nonlinear) is
not always certain.
Chronic Rejection
Recently, the term chronic rejection has taken on
new meanings. Kidney biopsies performed on patients Figure 6. “Capillaritis” in a biopsy specimen from a patient
with acute humoral rejection. Lymphocytes and granulocytes
with late declines in kidney function (ie, .1 year are present within peritubular capillaries (white arrows) (hema-
after transplantation) often show some combination toxylin and eosin stain).

Am J Kidney Dis. 2015;65(6):956-966 961

 Donald E. Hricik

and duplication of glomerular basement membranes blood group type ABO incompatible and those in
(ie, “tram-tracking”). When performed, electron mi- which recipients have significant preformed HLA
croscopy typically reveals duplication of glomerular antibodies to their donors. Active intervention to
basement membranes. The number of basement address the clinical problems of sensitization devel-
membrane layers may be directly correlated with oped in the mid-1990s. These have included desen-
worse transplant outcomes. In some cases, transplant sitization protocols and paired donor exchange
glomerulopathy appears more like idiopathic mem- programs (though the latter topic is outside the scope
branous nephropathy. Not surprisingly, analyses of of this review).
subepithelial deposits in such cases sometimes reveal
HLA antigens complexed with anti-HLA antibodies. ABO-Incompatible Desensitization
These observations suggest that some cases of “de ABO-incompatible donor-recipient combinations
novo” membranous nephropathy after kidney trans- have been successfully performed for more than 20
plantation actually represent a forme fruste of years. Patients with the A2 subtype of blood group A
antibody-mediated transplant glomerulopathy. express markedly reduced levels of A antigen on cell
Gene microarray analysis of tissue obtained from surfaces, which when first recognized led to the use of
serial transplant biopsies has been useful in depicting A2 donor organs for B and O recipients. The A1 red
the typical sequence of immune injuries after kidney blood cell surface contains about 1 million A anti-
transplantation. Messenger RNA transcripts suggest- gens, whereas the A2 erythrocyte contains only about
ing T-cell injury occur early after transplantation 250,000. For potential recipients with low levels of
(first year) and appear to be reversible with treatment. anti-A antibodies, kidneys from A2 donors behave
Transcripts suggesting evidence for B-cell activity more like blood group O donors and often can be
increase progressively beyond the first 6 months after transplanted without implementing specialized recip-
transplantation, indicating the increasing importance ient preconditioning.
of antibody-mediated injury over time. Nonadherence Transplantation across unacceptable ABO dispar-
to immunosuppressive medication regimens plays a ities in the absence of an A2 donor kidney or in the
role in almost 50% of cases of late humoral rejection. recipient with a high level of anti-A antibodies re-
quires recipient desensitization to the donor. Desen-
Additional Readings sitization protocols all implement similar principles
» Gago M, Cornell LD, Kremers WK, Stegall MD, Cosio FG. for recipient management: minimizing or eliminating
Kidney allograft inflammation and fibrosis, causes and con- the circulating DSAs, usually with plasmapheresis;
sequences. Am J Transplant. 2012;12(5):1199-1207. attenuating the subsequent immune response with
» Gaston RS, Cecka JM, Kasiske BL, et al. Evidence for
antibody-mediated injury as a major determinant of late
some combination of immunosuppression, intrave-
kidney allograft failure. Transplantation. 2010;90(1):68-74. nous immunoglobulin (IVIG), rituximab (ie, mono-
» Gloor JM, Sethi S, Stegall MD, et al. Transplant glomerul- clonal anti-CD20 antibody), or splenectomy; and
opathy: subclinical incidence and association with alloanti- active surveillance and early re-treatment if DSAs re-
body. Am J Transplant. 2007;7(9):2124-2132. emerge.
» Gourishankar S, Leduc R, Connett J, et al. Pathological and
clinical characterization of the ‘troubled transplant’: data Preformed Anti-HLA Antibody Desensitization
from the DeKAF study. Am J Transplant. 2010;10(2):324-
330. Implementing desensitization protocols for poten-
» Hricik DE, Nickerson P, Formica RN, et al. Multicenter tial transplant recipients who exhibit preformed
validation of urinary CXCL9 as a risk-stratifying biomarker donor-specific anti-HLA antibodies may be less
for kidney transplant injury. Am J Transplant. 2013;13(10):
2634-2644.
rewarding. Defining the antibody and its titer can
» Sellares J, Reeve J, Loupy A, et al. Molecular diagnosis of often predict the probability of successful desensiti-
antibody-mediated rejection in human kidney transplants. Am zation. It may be possible to successfully perform
J Transplant. 2013;13(4):971-983. transplantation on a recipient with a low antibody titer
» Solez K, Colvin RB, Racusen LC, et al. Banff 2007 classi- against single donor antigen without pretreatment;
fication of renal pathology: updates and future directions. Am
J Transplant. 2008;8(4):753-760.
however, in the recipient with a high PRA score
» Suthanthiran M, Schwartz JE, Ding R, et al. Urinary-cell (.30%) and high titers of antibodies against one or
mRNA profile and acute cellular rejection in kidney allo- more donor antigens, desensitization can be attemp-
grafts. N Engl J Med. 2013;369(1):20-31. ted. The goal of desensitization in this circumstance is
the marked reduction of antibody reactivity and not
PREVENTION OF REJECTION necessarily a negative cross-match. Desensitization is
rarely successful when recipients exhibit extremely
Desensitization Protocols high DSA titers. Because of variable outcomes and
Two types of immunologically incompatible donor- the large associated cost, only a minority of US trans-
recipient combinations have emerged: those that are plantation centers are currently using desensitization

962 Am J Kidney Dis. 2015;65(6):956-966

Core Curriculum in Nephrology

protocols for highly sensitized patients on a regular agents (rabbit antithymocyte globulin [ATG]
basis. [Thymoglobulin; Sanofi] and horse antithymocyte
Desensitization for patients with pre-existing anti- globulin [ATGAM; Pfizer]) and 2 monoclonal anti-
HLA antibodies is performed either with high doses bodies (basiliximab and alemtuzumab).
of IVIG given regularly (eg, monthly) until a negative Presently, rabbit ATG is the most popular poly-
cross-match is achieved or with plasmapheresis-based clonal antibody used in the United States, but it is
protocols similar to those used for ABO-incompatible technically prescribed off-label for induction therapy:
pairs, often using lower IVIG doses as adjunctive it is approved by the US Food and Drug Adminis-
therapy. The optimal strategy remains a subject of tration (FDA) only for the treatment of acute rejec-
considerable debate and controversy. These protocols tion. The reasons why rabbit ATG is effective are not
work best when a living donor is available for expe- fully understood. The preparation includes antibodies
ditious transplantation, but have also been applied to against many T-cell markers, including CD2, CD3,
patients awaiting deceased donor transplantation. CD4, CD8, CD11a, CD18, CD25, CD44, CD45,
Posttransplantation plasmapheresis and IVIG admin- HLA-DR, and HLA antigen class I heavy chains.
istration are generally continued for up to 2 weeks. Generally, treatment with rabbit ATG is associated
Persistently elevated antibody titers after trans- with profound lymphopenia, so much so that it has
plantation often portend transplant loss. Desensitiza- been classified as a T-cell–depleting antibody. The
tion protocols have clearly allowed kidney agent effectively suppresses cellular immune re-
transplantation in patients who may have not been sponses to a variety of antigenic stimuli, but may be
suitable for transplantation in an earlier era. However, less reliable in preventing antibody-mediated acute
these patients exhibit high rates of acute humoral rejection.
rejection requiring expensive treatment and may Currently available monoclonal induction anti-
exhibit poor long-term outcomes, raising questions bodies include basiliximab, which binds to the IL-2
about the cost-effectiveness of this strategy. Protea- receptor (CD25), and alemtuzumab, which binds to
some inhibitors and complement inhibitors have been CD52. Of these agents, only basiliximab is FDA
added to desensitization protocols at some centers, but approved for induction therapy. Today, alemtuzumab
are used more commonly to treat humoral rejection. is approved only for the treatment of lymphoma; in
transplant recipients, the drug causes lymphopenia
Induction Therapy that often is more profound and sustained than that
Induction therapy refers to using specific agents induced by polyclonal agents.
that usually are administered to the transplant recip- Induction immunotherapy sometimes involves the
ient on a short-term basis during the perioperative use of large doses of drugs that normally are reserved
period. Some of these agents have long-lasting effects for maintenance immunosuppression. A majority of
on the immune system, so their biological actions centers continue to administer high doses of cortico-
overlap with those of drugs used during the mainte- steroids during and for several days after trans-
nance phase. The aim of induction therapy is to pro- plantation. When administered in high doses, these
vide the transplanted organ with the opportunity to agents may inhibit the generation of inflammatory
survive the initial effector response by the host, a cytokines and limit the migration of cells into the
process essential to maintaining transplant function. transplant. In addition, steroids are often administered
One advantage of using antilymphocyte antibodies as to mollify the side effects of some of the induction
induction agents is a reduction in the incidence of antibodies.
acute rejection during the early posttransplantation
period. In theory, this avoids superimposition of im- Maintenance Immunosuppression
mune injury on a transplanted kidney that already Maintenance immunosuppression has evolved over
may be injured by perioperative factors, including the last 50 years, largely because of several seren-
ischemia-reperfusion injury. dipitous discoveries of new immunosuppressant
The benefits of using induction therapy must be drugs. Major improvements in long-term transplant
balanced against the toxicities of the various survival occurred during 3 major eras. The first, from
agents, the costs associated with the treatment, and 1954 to 1982, was based on a drug regimen that
the side effects of the agent used. Currently, w80% initially consisted of monotherapy with azathioprine,
of patients receiving kidney transplants in US and shortly thereafter, the combination of azathio-
medical centers receive some form of induction prine with corticosteroids. With this combination,
antibody therapy. Induction antibodies have been early acute rejection remained a major obstacle to
classified as either polyclonal or monoclonal even short-term transplant survival. In addition, these
agents. However, antibodies available for use in the medications were nonspecific in their ability to sup-
United States currently are limited to 2 polyclonal press immune responses.

Am J Kidney Dis. 2015;65(6):956-966 963

 Donald E. Hricik

Figure 7. Trends in the use of immunosuppressant drug classes between 1998 and 2011 at the time of hospital discharge
(dark lines) and at 1 year post-tx (light lines). Abbreviations: IL2-RA, interleukin 2 receptor antibody; mTOR, mammalian target of rapa-
mycin; tx, transplantation. Reproduced from the 2011 Annual Data Report of the Organ Procurement and Transplantation Network
(OPTN) and Scientific Registry of Transplant Recipients (SRTR).

The second era in transplant immunosuppression The availability of multiple immunosuppressive

started in 1982 with the introduction of cyclosporine, agents has allowed transplantation physicians to
a potent CNI that blocks IL-2 production and T-cell combine medications to take advantage of disparate
activation (signal 1 in the scheme described previ- mechanisms of action, with the goal of reducing
ously). Using cyclosporine resulted in markedly morbidity and optimizing outcomes. This has resulted in
improved transplant survival rates and a decreased significant controversy about which regimen of immu-
incidence of acute rejection. Between 1994 and 2001, nosuppressive medications may be the most efficacious.
the addition of a second CNI (tacrolimus) and a more Figure 7 depicts data from the 2011 Annual Report of the
selective antimetabolite (mycophenolate mofetil Scientific Registry of Transplant Recipients. Several
[MMF]) resulted in 1-year patient and transplant trends are obvious. First, tacrolimus has emerged as the
survival rates . 95% and .90%, respectively. Using CNI of choice. Second, MMF has largely replaced
combinations of these medications, acute transplant azathioprine. Third, the mTOR inhibitors have declined
rejection in low-risk nonsensitized patients is in popularity as de novo agents. Finally, almost 40% of
often ,10%, whereas even in high-risk patients, early patients are now managed without the use of cortico-
acute rejection occurs in ,25%. During this time, the steroids. As of 2011, the combination of tacrolimus and a
half-lives of kidney transplants slowly increased and mycophenolate acid derivative, with or without steroids,
chronic rejection replaced acute rejection as the main was used for maintenance therapy in just under 80% of
reason for organ failure and poor long-term function kidney transplant recipients in the United States.
in surviving patients.
The most recent era in the history of transplant Additional Readings
immunosuppression, beginning in the early 2000s,
saw the introduction of sirolimus, representing a » Augustine JJ, Bodziak KA, Hricik DE. Use of sirolimus in
solid organ transplantation. Drugs. 2007;67:369-391.
new class of drugs called mammalian TOR (mTOR) » Augustine JJ, Hricik DE. Steroid sparing in kidney trans-
inhibitors. Sirolimus is a powerful antiproliferative plantation: changing paradigms, improving outcomes, and
agent that blocks both lymphocyte and mesen- remaining questions. Clin J Am Soc Nephrol. 2006;1(5):
chymal cell proliferation (signal 3). In the same 1080-1089.
period, enteric-coated mycophenolic acid was » Brennan DC, Daller JA, Lake KD, et al. Rabbit antithymo-
cyte globulin versus basiliximab in renal transplantation.
introduced as an alternative to MMF, and a second N Engl J Med. 2006;355(19):1967-1977.
mTOR inhibitor, everolimus, was approved. » Fung JJ. Tacrolimus and transplantation: a decade in review.
Another major new drug class introduced during Transplantation. 2004;77(9 Suppl):S41-S43.
this most recent era is belatacept, a fusion protein » Halloran P. Immunosuppressive drugs for kidney trans-
that blocks T-cell costimulation (signal 2) mediated plantation. N Engl J Med. 2004:351(26):2715-2729.
» Hanaway MJ, Woodle ES, Mulgaonkar S, et al. Alemtuzu-
by the B7-CD28 ligand. In clinical trials, belatacept mab induction in renal transplantation. N Engl J Med.
was used as an alternative to CNI (ie, cyclosporine) 2011;364:1909-1919.
therapy and was associated with better long-term » Jordan S. IVIG vs plasmapheresis for desensitization: which
kidney function despite higher rates of acute rejec- is better? Am J Transplant. 2006;6:346-351.
tion. This third era in the history of transplant » Meier-Kriesche HU, Steffen BJ, Hochberg AM, et al.
Mycophenolate mofetil versus azathioprine therapy is asso-
immunosuppression also has been marked by the ciated with a significant protection against long-term renal
proliferation of generic equivalents for cyclosporine, allograft function deterioration. Transplantation. 2003;75(8):
tacrolimus, and MMF. 1341-1346.

964 Am J Kidney Dis. 2015;65(6):956-966

Core Curriculum in Nephrology

» Montgomery RA, Hardy MA, Jordan SC, et al. Consensus underlying the immunomodulatory effects of IVIG
opinion from the antibody working group on the diagnosis, are incompletely understood, but may include
reporting and risk assessment for antibody-mediated rejection
and desensitization protocols. Transplantation. 2004;78(2):
Fc-receptor blockade, regulation of complement
181-185. components, modulation of cytokine secretion, sup-
» Nashan B, Moore R, Amlot P, et al. Randomized trial of pression of natural killer cell activity, downregulation
basiliximab versus placebo for control of acute cellular of NFkB (nuclear factor-kB) activation, and attenua-
rejection in renal allograft recipients. Lancet. 1997; tion of T-cell stimulation.
350(9086):1193-1198
» Padiyar A, Augustine JJ, Hricik DE. Induction antibody
Two classes of agents, proteasome inhibitors and
therapy in kidney transplantation. Am J Kidney Dis. complement inhibitors, are now being used experi-
2009;54(5):935-944. mentally as additional adjuncts to treat acute humoral
» Stegall MD, Gloor J, Winters JL, et al. A comparison of rejection. Proteasomes are cellular complexes that
plasmapheresis versus high-dose IVIg desensitization in renal serve to contain fragments of cellular proteins that
allograft recipients with high levels of donor specific allo-
antibody. Am J Transplant. 2006;6:346-351.
otherwise would lead to apoptosis of the cell. Pro-
» Vincenti F1, Larsen C, Durrbach A, et al. Costimulation teasome inhibitors effectively induce apoptosis in
blockade with belatacept in renal transplantation. N Engl J cells, such as plasma cells, that produce abundant
Med. 2005;353(8):770-781. amounts of proteins. Bortezemib, a proteasome in-
» Vo AA, Choi J, Cisneros K. Benefits of rituximab combined hibitor currently approved for treating multiple
with intravenous immunoglobulin for desensitization in kid-
ney transplant recipients. Transplantation. 2014;98:312-319.
myeloma, has been used in combination with tradi-
» Watson CJ, Bradley JA, Friend PJ, et al. Alemtuzumab tional therapies for treatment of acute humoral rejec-
(CAMPATH 1H) induction therapy in cadaveric kidney tion and appears to have its largest benefit in early
transplantation—efficacy and safety at five years. Am J cases (occurring in the first 6 months after trans-
Transplant. 2005;5(6):1347-1353. plantation). Complement inhibitors offer the theoret-
» Webster AC, Lee VW, Chapman JR, et al. Target of rapa-
mycin inhibitors (sirolimus and everolimus) for primary
ical benefit of inhibiting complement-dependent
immunosuppression of kidney transplant recipients: a sys- antibody injury even if the antibodies are present.
tematic review and meta-analysis of randomized trials. Eculizumab, currently approved only for treating
Transplantation. 2006;81:1234-1248. paroxysmal nocturnal hemoglobinuria, is a mono-
» http://www.srtr.org/national_stats.aspx. clonal anti-C5 antibody that has shown some benefit
as an adjunctive treatment for acute humoral rejection.
TREATMENT OF REJECTION
Chronic Rejection
Acute Cellular Rejection
Treatment of chronic antibody-mediated rejection
Acute cellular rejection that is believed to be clin- has been disappointing, possibly because the patho-
ically or histologically mild is frequently treated at physiology remains poorly understood and lesions
first with large “pulse” doses of corticosteroids. such as transplant glomerulopathy often coexist with
Antilymphocyte preparations are used in patients for other chronic histologic changes (eg, IFTA). Virtually
whom pulse steroid therapy is not effective or for all the measures described in the preceding for treat-
those initially presenting with clinically or histologi- ing acute rejection (described here) have been used
cally severe rejection. In the current era, rabbit ATG for treating chronic rejection with variable and often
is the most commonly used agent. unsatisfactory results. Use of angiotensin-converting
enzyme inhibitors should be routine in patients with
Acute Humoral Rejection heavy proteinuria. In patients with circulating DSAs,
Algorithms for treating acute antibody-mediated minimizing or eliminating CNIs is not recommended
rejection are less well established and vary widely because reduced exposure to these agents may pro-
from center to center. Traditional antilymphocyte mote further antibody development.
antibodies are often used adjunctively to treat
antibody-mediated rejection, especially when there is Additional Readings
suspicion that cellular rejection might also be occur- » Gaber AO, First MR, Tesi RJ, et al. Results of a double-blind,
ring. However, plasmapheresis, anti-CD20 antibodies randomized, multicenter, phase III clinical trial of thymo-
globulin versus ATGAM in the treatment of acute graft
(ie, rituximab), and/or IVIG are now the modalities rejection episodes after renal transplantation. Trans-
most commonly used for primary treatment of hu- plantation. 1998;66(1):29-37.
moral rejection. The duration of pheresis varies » Gupta G, Abu Jawdeh BG, Racusen LC, et al. Late antibody-
widely, but most often is dictated by changes in the mediated rejection in renal allografts: outcome after con-
titers of the offending DSAs. IVIG may be adminis- ventional and novel therapies. Transplantation. 2014;97(12):
1240-1246.
tered intermittently (eg, after each plasmapheresis » Roberts DM, Jiang SH, Chadban SJ. The treatment of acute
session) or occasionally in larger doses only after antibody-mediated rejection in kidney transplant recipients—
completing a course of pheresis. The mechanisms a systematic review. Transplantation. 2012;94(8):775-783.

Am J Kidney Dis. 2015;65(6):956-966 965

 Donald E. Hricik

» Sapir T, Shoenfield Y. Facing the enigma of immunomodu- phenotypes of Treg (eg, those that are CD25-, CD4-,
latory effects of intravenous immunoglobulin. Clin Rev Al- and Foxp3-positive) as well as newly developed
lergy Immunol. 2005;29(3):185-199.
» Stegall MD, Diwan T, Raghavaiah S, et al. Terminal com-
methods for inducing Treg expansion in vitro and
plement inhibition decreases antibody-mediated rejection in in vivo, has excited the transplant community. While
sensitized renal transplant recipients. Am J Transplant. only limited success has been achieved in developing
2011;11(11):2405-2413. human allograft tolerance in humans, multiple groups
are studying whether and how Tregs can be exploited
STRATEGIES FOR ACHIEVING TOLERANCE to prolong transplant survival and potentially induce
One ultimate goal of transplantation is to induce robust transplant tolerance.
immunologic tolerance to the transplant such that the
host’s immune system is intact (can respond normally Additional Readings
to immune stimuli) without immunosuppression and » Fudaba Y, Spitzer TR, Shaffer J, et al. Myeloma responses
with the specific absence of a detrimental immune and tolerance following combined kidney and non-
response directed at the transplanted organ. Studies in myeloablative marrow transplantation: in vivo and in vitro
animal models have suggested that tolerance to a analyses. Am J Transplant. 2007;7(2):347-355.
transplant can be achieved under certain conditions, » Kawai T, Cosimi AB, Sachs DH. Preclinical and clinical
studies on the induction of renal allograft tolerance through
including removal of the donor-reactive immune cells transient mixed chimerism. Curr Opin Organ Transplant.
(deletion), induction of immunologic ignorance (so 2011;16(4):366-371.
the immune system never “sees” the transplant anti- » Kawai T1, Sachs DH, Sprangers B, et al. Long-term results in
gens), induction of anergy (nonresponsiveness), or recipients of combined HLA-mismatched kidney and bone
active inhibition by Tregs. Immunologic tolerance has marrow transplantation without maintenance immunosup-
pression. Am J Transplant. 2014;14(7):1599-1611.
been achieved in human kidney transplant recipients » Leventhal J, Abecassis M, Miller J, et al. Tolerance induction
when bone marrow transplantation has been per- in HLA disparate living donor kidney transplantation by
formed between HLA antigen–identical donors, fol- donor stem cell infusion: durable chimerism predicts
lowed by kidney transplantation using the same outcome. Transplantation. 2013;95(1):169-176.
donor. Based on these experiments of nature, several » Scandling JD, Busque S, Dejbakhsh-Jones S, et al. Tolerance
and withdrawal of immunosuppressive drugs in patients
groups have attempted to use bone marrow ablation given kidney and hematopoietic cell transplants. Am J
with either marrow or stem cell transplantation and Transplant. 2012;12(5):1133-1145.
adjunctive cocktails of early immunosuppression in » Waldmann H, Chen TC, Graca L, et al. Regulatory T cells in
an effort to achieve long-term tolerance. Results have transplantation. Semin Immunol. 2006;18(2):111-119.
been variably successful, but the cost-effectiveness
and safety of these strategies have been open to ACKNOWLEDGEMENTS
question.
The author thanks Dr Peter Heeger for creating Figs 1 to 4.
Tregs suppress immune responses, potentially by Support: None.
local cytokine production and prevention of dendritic Financial Disclosure: The author declares that he has no rele-
cell activation. The recent recognition of multiple vant financial interests.

966 Am J Kidney Dis. 2015;65(6):956-966