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  • Review Article
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The impact of infection and tissue damage in solid-organ transplantation

Nature Reviews Immunology volume 12, pages 459–471 (2012)Cite this article

Subjects

Key Points

  • The type and timing of an infection influences its impact on alloreactivity and transplantation outcome. Infections before transplantation can generate pathogen-specific memory T cells that cross-react with allogeneic MHC molecules through direct allorecognition — a process termed heterologous immunity. The high frequency of memory T cells generated through heterologous immunity is thought to serve as a major barrier to transplantation tolerance in humans.

  • Tissue damage and infections are common following transplantation, especially in the immediate post-transplant period, and an increased risk for infection persists as a result of lifelong pharmacological immunosuppression. Tissue damage releases damage-associated molecular patterns (DAMPs), whereas infections release pathogen-associated molecular patterns (PAMPs). Both sets of molecules can stimulate innate immunity and enhance alloreactivity.

  • Pattern-recognition receptor (PRR)-mediated signals can directly enhance antigen-presenting cell (APC) maturation, upregulate the expression of co-stimulatory ligands, increase antigen presentation and induce the production of pro-inflammatory cytokines. Cytokines can function in a localized manner by enhancing cognate APC–T cell interactions, but they can also have systemic effects that promote the activation and define the differentiation of bystander alloreactive T cells.

  • Some infections may have systemic immunosuppressive effects by triggering the release of glucocorticoids. This glucocorticoid release is crucial for limiting the pathogenicity of microorganism-specific immune responses, but it can also result in an increased susceptibility to secondary infections and a transient suppression of alloreactivity.

  • Tissue damage that arises during the brain or cardiac death of the transplant donor, from cold ischaemia (owing to the storage and transport of procured donor organs) followed by reperfusion in the recipient, from warm ischaemia and as a result of surgically induced injury can cause the release of DAMPs, which can stimulate inflammation and innate immunity. Furthermore, DAMPs released by infected cells can synergize with PAMPs to stimulate alloreactivity and promote rejection.

  • An increasing number of agonists and antagonists targeting PRRs are being developed for the treatment of cancer, autoimmunity and inflammatory diseases. These drugs may be useful in reducing ischaemia–reperfusion injury and the stimulatory effects of infection on alloreactivity. However, success in this approach depends on identifying pathways that block the stimulation of alloreactivity but leave protective immunity to infections intact.

Abstract

Investigations over the past two decades are revealing complexities in the regulation of the innate immune response, and how this response, in turn, controls adaptive immunity. Microbial exposure, infections and tissue damage that accompany solid-organ transplantation result in the release of pathogen- and damage-associated molecular patterns, as well as pathogen- or allograft-derived antigens. Here, we review these triggers of innate and adaptive immunity, and discuss emerging paradigms of the many ways in which infections and tissue damage might directly or indirectly affect alloreactivity and the outcome of transplanted allografts.

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Figure 1: Possible effects of infections before, at and after transplantation.
Figure 2: Antimicrobial immune responses can augment and shape alloimmunity.
Figure 3: Potential causes of graft damage during microbial infections.

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Acknowledgements

We apologize to the many authors whose papers could not be cited or fully discussed owing to space limitations. We thank S. Bhorade, M. Josephson, C. Nagler, M. Miller, K. Pursell and J. Williams for their critical reading of the manuscript. This work was supported in part by US National Institute of Allergy and Infectious Diseases (NIAID) grant R01 AI071080 to M.-L.A., and by Roche Organ Transplantation Research Foundation grant 979162997 and NIAID grant R01 AI072630 to A.S.C.

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  1. Department of Medicine, The University of Chicago, 924 East 57th Street, Chicago, Illinois 60637, USA.

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  1. Department of Surgery, The University of Chicago, 5841 South Maryland Avenue, Chicago, 60637, Illinois, USA

    Anita S. Chong & Maria-Luisa Alegre

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  1. Anita S. Chong
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  2. Maria-Luisa Alegre
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Correspondence to Anita S. Chong.

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Glossary

Minor histocompatibility antigens

In the context of solid-organ transplantation, minor histocompatibility antigens are derived from polymorphic alleles of genes that differ between the donor and recipient. These minor antigens are presented as peptides on recipient MHC molecules to recipient T cells, which then cause the rejection of the grafted organ.

Ischaemia–reperfusion injury

Cellular damage caused by the return of blood flow to a tissue after a period of inadequate blood supply. The absence of oxygen and nutrients causes cellular damage and the restoration of blood flow results in inflammation.

Donor-specific transfusion

(DST). A treatment for inducing transplant tolerance that involves the infusion into a transplant recipient of spleen cells from a donor who also provides the organ or tissue.

MHC tetramers

Fluorescently labelled tetravalent complexes of MHC class I or class II molecules complexed with antigenic peptides. They can be used to identify antigen-specific T cells by flow cytometry.

Severe combined immunodeficiency mice

(SCID mice). Mice with a defect in DNA recombination that results in an absence of B and T cell development. Such mice are incompetent at rejecting tissue grafts from allogeneic and xenogeneic sources.

Superantigen

A microbial protein that activates all T cells expressing a particular set of T cell receptor (TCR) Vβ chains by crosslinking the TCR to a particular MHC molecule regardless of the peptide presented.

Graft-versus-host disease

(GVHD). Tissue damage in a recipient of allogeneic tissue resulting from the activity of donor lymphocytes that recognize the tissues of the recipient as foreign. GVHD varies markedly in extent, but it can be life-threatening in severe cases. Damage to the liver, skin and gut mucosa are common clinical manifestations.

Bronchiolitis obliterans syndrome

(BOS). A fibroproliferative process of the small airways that results in multifocal bronchiolar obliterations and is presumed to reflect chronic Iung allograft rejection. BOS is the major factor that limits the survival of lung transplant recipients.

Glucocorticoids

A group of compounds that belong to the corticosteroid family. These compounds can be either naturally produced (hormones) or synthetic. They affect metabolism and have anti-inflammatory and immunosuppressive effects. Many synthetic glucocorticoids (for example, dexamethasone) are used in clinical medicine as anti-inflammatory drugs.

Haptoglobin

A plasma protein that can bind to free haemoglobin in the bloodstream.

Endotoxemia

Endotoxemia is caused by the presence in the blood of lipopolysaccharide (endotoxin), which is derived from Gram-negative bacteria. It results in systemic activation of the inflammatory response, the development of shock, multi-organ failure and death. Models of endotoxemia are used in experimental settings to induce systemic inflammation, but they do not necessarily mimic human sepsis.

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Chong, A., Alegre, ML. The impact of infection and tissue damage in solid-organ transplantation. Nat Rev Immunol 12, 459–471 (2012). https://doi.org/10.1038/nri3215

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