First Aid, Chapter 1 Immune Mechanisms, Transplantation and Tumor Immunology Flashcards

1
Q

What kind of rejection can ABO incompatibility cause in solid organ grafts? Why?

A

Hyperacute rejection.

  • ABO blood group antigens are present on all tissues, including kidney and cardiac grafts.
  • Preformed, naturally occurring antibodies to blood group substances are present in mismatched recipients.
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2
Q

How are HLA antigens inherited?

A

In a Mendelian dominant manner.

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3
Q

Why are HLA genes almost always inherited together? What is the fixed combination of genetic determinants called?

A

Because of the closeness of the different loci of the MHC and the resultant low cross-over frequency. The fixed combination is a haplotype.

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4
Q

How many haplotypes does each individual receive? Why?

A

Since chromosome 6 is an autosome, all individuals have two expressed HLA haplotypes (maternal and paternal).

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5
Q

How many possible haplotype combinations do offspring have of any two parents?

A

4

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6
Q

What type of solid organic rejection can HLA mismatching cause? Why?

A

HLA antibodies—Individuals exposed to non-self-HLA antigens can develop anti-HLA antibodies. These antibodies, like ABO incompatibility, can cause hyperacute rejection of a solid organ expressing those HLA antigens.

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7
Q

What methods are there to detect antibody mismatches between donor and recipient?

A

Serological cross matching and donor recipient matching via detecting HLA antigens either serologically or by DNA typing or measuring the response of immunocompetent cells from recipient to antigens present on donor cells

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8
Q

What types of grafts is serologic cross-matching particularly important in? Why? What is screened for in serologic cross-matching? What type of transplant is positive serologic crossmatching an absolute contraindication for?

A

Important in kidney and heart because they are highly vascularized. Serum from the prospective recipient is tested against cells from the potential donor for presence of antibodies to RBC or HLA antigens. Positive serologic crossmatch is an absolute contraindication to renal transplantation.

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9
Q

What type of graft rejection does antibodies to RBC and HLA cause?

A

Hyperacute graft rejection.

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10
Q

How is donor-recipient matching done?

A
  • Detect HLA antigens on donor and recipient leukocytes by either serologic or DNA typing.
  • Measure response of immunocompetent cells from recipient to antigens present on donor cells (and vice versa for bone marrow transplantation).
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11
Q

What types of transplants are not HLA matched and why?

A

Heart, lung, and liver transplants are often not HLA-matched (primarily due to time considerations).

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12
Q

How are antigen mismatches detected in screening for organ transplant?

A

Antigen Mismatches = disparities that are serologically detected.

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13
Q

How are allele mistmatches detected in screening for organ transplant?

A

Allele Mismatches = differences that can be identified only by DNA-based typing

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14
Q

When does hyperacute rejection occur? What is the onset? What is the immune component that it is mediated by? What is the damage seen to the tissue?

A

-timing

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15
Q

When does accelerated rejection occur? What is the onset? What is the immune component that it is mediated by? What is the damage seen to the tissue?

A
  • Timing 3-5 days
  • onset 1 day
  • immune component: noncomplement fixing ab, NK cells, and monocytes
  • vascular disruption and hemorrhage
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16
Q

When does acute rejection occur? What is the onset? What is the immune component that it is mediated by? What is the damage seen to the tissue?

A
  • timing 6-90 days
  • onset days to weeks
  • immune component: T lymphocytes (CD4+ and CD8+) and antibodies
  • tubulitis, interstitial inflammation, parenchymal cell damage, and endovasculitis
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17
Q

When does chronic rejection occur? What is the onset? What is the immune component that it is mediated by? What is the damage seen to the tissue?

A
  • timing >60 days
  • onset months to years
  • Immune component Ab and inflammatory cytokines
  • vascular onion skinning (fibrosis) on biopsy, along with delayed-type hypersensitivity (DTH) in vessel wall, intimal proliferation, and vessel occlusion.
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18
Q

What post-op immunosuppression is used to reduce the risk of rejection?

A

Postoperative immunosuppression, using corticosteroids, antithymocyte globulin, tacrolimus, and cyclosporine is used to reduce the risk of rejection.

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19
Q

Describe hyperacute rejection in histologic terms.

A

Hyperacute rejection in a transplanted kidney demonstrating acute tubular necrosis. All of the tubules are necrotic with sloughed pink epithelial cells and debris, with loss of nuclear detail.

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20
Q

What is the chance of rejection of transplants in order from highest to lowest matching?

A

Mismatched
Matched unrelated
Matched 1st-degree relative
Syngeneic (identical twin)

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21
Q

What are high-risk groups for hyperacute and accelerated rejection?

A

High-risk groups for hyperacute and accelerated rejection are multiparous women and multiple transfusion recipients.

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22
Q

What types of transplant rejections does having preformed antibodies predict?

A

Hyperacute and accelerated rejection.

23
Q

How is screening for preformed antibodies done?

A
  • Pretransplant screen for presence of antidonor HLA antibodies to panel of potential donors
  • Expressed as percentage of reactive antibodies (PRA)
24
Q

How do antibodies cause graft rejection? What type of rejection is it involved it

A
  • Antibodies combine with HLA antigens on endothelial cells with subsequent complement fixation and accumulation of polymorphonuclear cells.
  • Endothelial damage then occurs secondary to enzymes released form polymorphonuclear (PMN) leukocytes.
  • Platelets later accumulate, thrombi develop, and the result is renal cortical necrosis or myocardial infarction.
  • hyperacute rejection, particularly of highly vascularized organs such as kidney and heart.
25
Q

How is innate immunity involved in graft rejection? What cells are involved? What type of rejection?

A

Innate Immunity—Natural killer cells and monocytes are effector cells of accelerated rejection via antigen-dependent cell-mediated cytotoxicity (ADCC).

26
Q

How do leukocytes and cytokines impact allograft rejection?

A
  • Allograft rejection results from coordinated activation of alloreactive T lymphocytes and APCs.
  • Primed helper T lymphocytes release multiple cytokines: IL-2, IL-4, IL-5, IL7, IL-10, IL-15, TNFα, and IFNγ.
  • Cause recruitment of primarily immunocompetent donor-specific CD4+ T lymphocytes; also CD8+ cytotoxic T lymphocytes, antibody-forming B lymphocytes, and nonspecific inflammatory cells.
27
Q

Stimulation of CD4+ T lymphocytes through antigen receptor is not sufficient to initiate T-lymphocyte activation. What else is needed?

A

Activation of CD4+ T lymphocytes needs costimulation.

-Signaling must occur through one of the costimulators:
o Receptor: Ligand interactions (Table 1-30)
o IL-1 and IL-6 on APCs

28
Q

How does tolerance of grafts occur via T cells?

A

Tolerance induction occurs when T-cell receptor interacts with APCs. As a result, T–lymphocyte-accessory proteins and ligands on APCs are target molecules for antirejection therapy.

29
Q
What are the ligands on APCs for the following receptors on T lymphocytes? 
CD2
CD11a/CD18
CD5
CD40L
CD28
A
CD2: CD58 
CD11a/CD18: CD54 
CD5: CD72 
CD40L: CD40 
CD28: CD80 or CD86
30
Q

How are CD8+ T lymphocytes activated in graft rejection? What role do CD8+ T lymphocytes play in graft rejection?

A

CD8+ T lymphocytes recognize antigenic peptides on MHC class I molecules and represent a major cytotoxic effector lymphocyte population in graft rejection.

  • CD8+ activation requires second signal + IL-2.
  • CD8+ activation signaling occurs through γ chain of multiple cytokine receptors.
  • Activated CD8 cells proliferate and mature into specific alloreactive clones capable of releasing granzymes, perforin, and toxic cytokines such as TNFα.
31
Q

Describe the steps that lead to graft rejection after T lymphocyte activation occurs?

A
  • Autocrine T-lymphocyte proliferation continues secondary to expression of IL-2R. The IL-2 or IL-2R interactions trigger kinases, leading to Raf-1 activation and expression of DNA binding proteins, Jun, c-Fos, and c-Myc. This results in graft-specific T lymphocytes.
  • T-lymphocyte cytokines also activate macrophages, leukocytes, and upregulate HLA on graft cells.
  • Activated T lymphocytes stimulate B lymphocytes to make autograft antibody.
  • Ultimately, all cellular and humoral factors destroy graft.
32
Q

How do cyclosporine and tacrolimus interfere with graft rejection?

A

Cyclosporine and tacrolimus interfere with activating process involving T-cell receptors and costimulatory molecule CD28:CD80 or CD86.

33
Q

Describe the mechanism of Cyclosporin and tacrolimus in management of graft rejection?

A

Cyclosporin binds to cyclophilin → inhibition of calcineurin → blockade of NFAT activation → inhibition of transcription of IL-2 → inhibition of T-cell differentiation

34
Q

What is the mechanism of rapamycin in management of graft rejection?

A

Rapamycin binds to FKBP → binds to mTOR → inhibition of mTOR → blockade of T-cell proliferation

35
Q

How does mycophenolate mofetil (MMF) inhibit graft rejection?

A

Inhibition of guanine nucleotide synthesis → T-cell proliferation halted

36
Q

How does azathioprine inhibit graft rejection?

A

Blockade of lymphocyte precursors (less-specific than MMF → higher toxicity)

37
Q

What are drugs in the category of metabolic toxins that inhibit proliferating T cells?

A

Mycophenolate mofetil (MMF) and azathioprine

38
Q

What are drugs that are inhibitors of T lymphocytes and their activation?

A

Cyclosporin (CsA), FK 506 (tacrolimus), and rapamycin

39
Q

What are drugs that are antibodies to T cell antigens?

A

Anti-CD3 and Anti-CD25 (a subunit of IL2R)

40
Q

What is the mechanism of action of anti-CD3 in management of graft rejection?

A

Monoclonal Ab binding to CD3 → promote phagocytosis or complement-mediated lysis of T cells

41
Q

What is the mechanism of action of Anti-CD25 (a subunit of IL2R) in management of graft rejection?

A

Blockade of IL-2 binding to activated T cells that express CD25 → prevention of T-cell activation

42
Q

What is the mechanism of corticosteroids in management of graft rejection?

A

Block synthesis and secretion of cytokines from macrophages

43
Q

What cells are early tumor lesions infiltrated with?

A

Early lesions are infiltrated with hematopoietic cells, including lymphocytes, macrophages, and occasionally granulocytes.

44
Q

What cells are in tumor lesions in late stages of tumor development in colon, breast, and oral carncinomas? Describe the cells and the markers on the cells.

A

An abundance of tumor infiltrating lymphocytes (TILs).

o TILs: Small-to-large lymphocytes that are mostly CD3+ CD95+ TCR-α/β + T lymphocytes.

45
Q

The presence of what chain in tumor infiltrating lymphocytes is associated with improved patient survival? Why? What marker is present on these cells?

A

The presence of the TILs with a normal ζ chain is associated with improved patient survival. This results in normal signaling through the TCR. These cells are typically CD95+ (Fas).

46
Q

Cyclosporin inhibits calcineurin and blocks NFAT activation by binding to which molecule?

A

Cyclophilin

47
Q

What does TNF induce apoptosis through?

A

TNF family receptors. Include FasL, TRAIL, and TNF.

48
Q

What immunoinhibitory cytokines do tumors produce?

A

TGFβ, IL-10, GM-CSF, and ζ-inhibiting protein (ZIP).

49
Q

What immunoinhibitory small molecules do human tumors produce? How do they inhibit leukocytes?

A

Prostaglandin E2, epinephrine, and reactive oxygen metabolites (ROMs). Inhibit leukocyte functions via increased cyclic adenosine monophosphate (cAMP) or superoxide generation.

50
Q

What virally related immunohibitory products do human tumors produce?

A

p15E and EBI-3

51
Q

What do tumor-associated gangliosides do?

A

Inhibit IL-2-dependent lymphocyte proliferation, induce apoptotic signals, suppress NFkB activation, and interfere with dendritic cell generation.

52
Q

Are tumors ignored by the immune system? In what ways?

A

No.

  • Cancer patients have a higher amount of tumor-specific T lymphocytes in circulation that recognize class I or class II MHC-restricted tumor epitopes.
  • Tumor-specific T lymphocytes, in the presence of cytokines, can increase and target tumor cells for destruction.
  • Tumor-specific T lymphocyte can be used to recognize T–lymphocyte-defined tumor epitopes.
  • Antitumor antibodies in patients allow for identification of serologically defined tumor antigens.
53
Q

How do NK cells prevent metastases?

A

NK cells are important in preventing metastasis of tumors by eliminating tumor cells in the circulation through perforin-mediated lysis and apoptosis of tumor cell targets.

54
Q

What are killer cell immunoglobulin-like receptors (KIR)?

A

Inhibitor receptors on NK cells known as killer cell immunoglobulin-like receptors (KIR) recognize MHC class I and assist NK cells in sampling healthy cells to look for abnormal cells that have lost the self-determinants on their surface.