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Current Topics in Pathology 92 Current Topics in Pathology 92 Managing Editors C.L. Berry J. Prat Editorial Board W. Boeker, H. Cottier, P. J. Dawson, H. Denk C. M. Fenoglio-Preiser, P. U. Heitz, O. H. Iversen U. Lohrs, F. Nogales, U. Pfeifer, N. Sasano G. Seifert,J.C.E. Underwood, Y. Watanabe Springer Berlin Heidelberg New York Barcelona Hong Kong London Milan Paris Singapore Tokyo c. L. Berry (Ed.) Transplantation Pathology A Guide for Practicing Pathologists Contributors E. Alvarez-Fernandez, K. Atkinson, S. M. Dodd, D. A. Hilton C. C. Kibbler, G. Koukoulis, S. Love, J. P. Mindan, A. Panizo B. Portmann, E. Thorsby, F. Vartdal Springer Dr. med. Beat Thurlimann Kantonsspital St. Gallen Klinik C fur Innere Medizin Abteilung fUr Onkologie und Hamatologie CH-9007 St. Gallen ISBN-13:978-3-642-64162-6 e-ISBN-13:978-3-642-59877-7 DOl: 10.1007/978-3-642-59877-7 ISSN 0080-0015 Library of Congress Cataloging-in-Publication Data Bisphosphonates in clinical oncology: the development in pamidronate/B. Thiirlimann (ed.). p. cm. - (Recent results in cancer research, ISSN 0080-0015; 149). Includes biblio­ graphical references and index.ISBN-13:978-3-642-64162-6(hardcover: alk.paper).1.Disodium pamidronate. 2. Bones-Cancer-Chemotherapy. 3. Diphosphonates-Therapeutic use. I. Thiirlimann, B. (Beat), 1955-. II. Series. [DNLM: 1. Diphosphonates-pharmacology. 2. Antineoplastic Agents-pharmacology. 3. Hypercalcemia-drug therapy. 4. Bone Neo­ plasms-drug therapy. 5. Bone Neoplasms-secondary. 6. Bone and Bones-physiolo­ gy. [WI REI06P v. 149 1998/QZ 267 B6157 1998] RC261R35 vol. 149 [RC280.B6] 616.99'4 s [616.99'4061]-DC21 DNLM/DLC for Library of Congress. This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illus­ trations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Viola­ tions are liable for prosecution under the German Copyright Law. © Springer-Verlag Berlin· Heidelberg 1999 Sof trover reprint of the hardcover I st edition 1999 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Production: PRO EDIT GmbH, D-69126 Heidelberg Typesetting: K+V Fotosatz GmbH, D-64743 Beerfelden SPIN 10643981 19/3133-5 4 3 2 1 0 - Printed on acid-free paper List of Contributors ALVAREZ-FERNANDEZ, E. Professor Titular de Anatomia Patol6gica, MD,PhD Head Departamento de Anatomia Patol6gica Hospital General Universitario Gregorio Marafion Doctor Esquerdo, 46 28007 Madrid, Spain ATKINSON, K. Director of Clinical Transplantation MD, FRCP, FRACP SyStemix, Inc. 3155 Porter Dr. Palo Alto, CA 94304, USA DODD, S.M. Senior Lecturer in Dr. Department of Morbid Anatomy and Histopathology St. Bartholomew's and the Royal London School of Medicine and Dentistry Royal London Hospital Whitechapel London El lBB, UK HILTON,D.A. Consultant Neuropathologist Prof. Department of Histopathology Derriford Hospital Plymouth PL6 8DH, UK KIBBLER, C. C. Consultant in Medical Microbiology MA, FRCP, FRCPath Royal Free Hospital Pond Street London NW3 2QG, UK KOUKOULIS, G. Formerly: Institute of Liver Studies King's College Hospital Denmark Hill London SE5 9 RS, UK VI List of Contributors LOVE,S. Professor of Neuropathology Prof. Department of Neuropathology Frenchay Hospital Bristol BS16 lLE, UK MINDAN,J.P. Departamento de Anatomia Patologica Prof. Clinica Universitaria Universidad de Navarra 31080 Pamplona, Spain PANIZO,A. Departamento de Anatomia Patologica Prof. Clinica Universitaria Universidad de Navarra 31080 Pamplona, Spain PORTMANN, B. Professor of Hepatopathology and Hon. MD,FRCPath Consultant Histopathologist Institute of Liver Studies King's College Hospital Denmark Hill London SES 9 RS, UK THORSBY,E. Institute of Transplantation Immunology Prof. The National Hospital and University of Oslo Rikshospitalet 0027 Oslo, Norway VARTDAL,F. Institute of Transplantation Immunology Prof. The National Hospital and University of Oslo Rikshospitalet 0027 Oslo, Norway Preface The widespread use of transplantation in an increasing range of diseases has meant that many pathologists, other than those in special centres, are seeing material from transplanted patients. It is also increasingly necessary for those in training to understand the essential features of transplant related pathology; many of the institutions in which they will work will have transplant programmes. This volume attempts to give a clear account of how patients with the commonly transplanted tissues and organs are managed by the use of pathological techniques. The emphasis is on the important com­ plications of rejection and infection and in order to understand these, an outline of what is of basic scientific importance in rejection is given. Finally, in a section on the central nervous system, the way in which transplantation may be used to inform us in terms of development, the pathogenesis of disease and with new developments in a group of conditions resistant to therapy is illustrated. The criteria for the evaluation of rejection are given, in terms of recent internationally agreed criteria, and there has been a deliberate attempt to give a critical valuation of the likelihood of the various in­ fectious complications. It is hoped that this volume will be a useful reference source for the specialist and that it will inform the generalist. London, November 1998 SIR COLIN BERRY Contents Transplantation Immunology - The Role of Human Leucocyte Antigen in Allorecognition F. VARTDAL and E. THORSBY ................ 1 Infections in Solid Organ Transplant Recipients C. C. KIBBLER ................... 19 Chronic Allograft Nephropathy: The Inevitable Outcome of Renal Transplantation? S.M.DoDD ..................... 37 Pathology of the Liver Allograft B. PORTMANN and G. KOUKOULIS 61 Bone-Marrow and Blood Stem-Cell Transplantation K.ATKINSON ............................. 107 Pathology of Heart Transplant J.P. MINDAN and A. PANIZO .... ............ 137 Pathology of Pulmonary Transplantation E.ALVAREZ-FERNANDEZ . ....... 167 Transplantation in the Central Nervous System S. LOVE and D.A. HILTON . 181 Subject Index ...... 215 Transplantation Immunology - The Role of Human Leucocyte Antigen in Allorecognition F. VARTDAL and E. THORSBY 1 Introduction ..................................... 1 2 Types of Transplantation . 2 3 Types of Rejection .................................. 2 4 Structure and Function of Human Leucocyte Antigen (HLA) Molecules .... 3 5 T Cell Recognition of Foreign Peptides Presented by Self-HLA . 5 6 Allorecognition . 6 6.1 Recognition by T Cells . 6 6.1.1 Indirect Allorecognition ............... 7 6.1.2 Direct Allorecognition . 7 6.2 Recognition by Natural Killer (NK) Cells . 8 6.3 Recognition by B Cells ... 8 7 Alloactivation . 8 7.1 Alloactivation of T Cells .. 8 7.2 Alloactivation of B Cells .. 10 8 Effector Mechanisms in Allograft Rejection .................... 11 9 Role of HLA Matching in Clinical Transplantation ................ 12 10 Specific Immunosuppression ............................ 13 10.1 Mechanisms for the Maintenance of Specific Non-responsiveness: Tolerance .. 13 10.1.1 Deletion ........................................ 13 10.1.2 Ignorance and Anergy . 14 10.1.3 Suppression . 14 10.2 Methods for the Induction of Specific Non-responsiveness: Tolerance ...... 14 11 Concluding Remarks . 15 References . 15 1 Introduction Transplantation of organs and bone marrow is the therapy of choice for an increas­ ing number of patients. The greatest problem encountered after transplantation of cells and tissue from a genetically different donor is that the immune system of the recipient recognizes the transplant as foreign and will try get rid of it in essentially the same way as the immune system deals with invading organisms. The result is a host-versus-graft (HVG) response, which may lead to rejection of the transplant. Similarly, T lymphocytes (T cells for short) transferred along with the stem cells in a donor bone marrow graft can recognize host cells as foreign and will initiate a graft-versus-host (GVH) response, which may cause serious and often fatal GVH disease. Human leucocyte antigen (HLA) molecules play an instrumental role in trigger­ ing both HVG and GVH immune responses. In this chapter, we first describe the Current Topics in Pathology Volume 92, C. L. Berry (Ed.) © Springer-Verlag Berlin Heidelberg 1999 2 F. VARTDAL and E. THORSBY structure and normal biological function of HLA molecules and how these mole­ cules are involved in the recognition of foreign cells, i. e., in allorecognition. The activation and effector mechanisms of alloimmune responses are then treated briefly, followed by a discussion of the role of HLA matching and of the various strategies used to induce donor-specific tolerance. 2 Types ofTransplantation There are several types of transplantation and in each of these
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