Transplant rejection

Alternative names
Graft rejection; Tissue/organ rejection

Definition

Transplant rejection is when a transplant recipient’s immune system attacks a transplanted organ or tissue. See also graft-versus-host disease.

Causes, incidence, and risk factors

Your body’s immune system protects you from potentially harmful substances, such as microorganisms, toxins, and cancer cells. These harmful substances have proteins called antigens on their surfaces. If your immune system identifies antigens that are foreign (not part of your body), it will attack the substance.

In the same way, foreign blood or tissue can trigger a blood transfusion reaction or transplant rejection. To help prevent this, tissue is “typed” before the transplant procedure to identify the antigens it contains.

Though tissue typing ensures that the organ or tissue is as similar as possible to the tissues of the recipient, the match is usually not perfect. No two people (except identical twins) have identical tissue antigens.

Immunosuppressive drugs are needed to prevent organ rejection. Otherwise, organ and tissue transplantation would almost always cause an immune response and result in destruction of the foreign tissue.

There are some exceptions, however. Corneal transplants are rarely rejected because corneas have no blood supply - immune cells and antibodies do not reach the cornea to cause rejection. In addition, transplants from one identical twin to another are almost never rejected.

Symptoms

     
  • The organ does not function properly  
  • General discomfort, uneasiness, or ill feeling  
  • Pain or swelling in the location of the organ (rare)  
  • Fever (rare)

The symptoms vary depending on the transplanted organ or tissue. For example, patients who reject a kidney may have less urine, and patients who reject a heart may have symptoms of heart failure.

Signs and tests

The doctor will use his or her hands to feel over the organ, and this may feel tender to you (particularly with transplanted kidneys).

There are often signs that the organ isn’t functioning properly. For example:

     
  • Less urine output with kidney transplants  
  • Yellow skin color and easy bleeding with liver transplants  
  • Shortness of breath and less tolerance to exertion with heart transplants

A biopsy of the transplanted organ can confirm that it is being rejected. A routine biopsy is often performed to detect rejection early, before symptoms develop.

When organ rejection is suspected, one or more of the following tests may be performed prior to organ biopsy:

     
  • Lab tests of kidney or liver function  
  • Kidney ultrasound  
  • Kidney arteriography  
  • Abdominal CT scan  
  • Heart echocardiography  
  • Chest x-ray

Treatment

The goal of treatment is to make sure the transplanted organ or tissue functions properly, while at the same time suppressing the recipient’s immune response. Suppressing the immune response can treat and prevent transplant rejection.

Many different drugs can be used to suppress the immune response. These include azathioprine, cyclosporine, corticosteroids (such as prednisone), and OKT2 monoclonal antibodies. OKT2 monoclonal antibodies specifically reduce the activity of T lymphocytes, which are the main immune system cells responsible for transplant rejection.

The dosage of the medication depends on the patient’s status. The dose may be very high while the tissue is actually being rejected, and then reduced to a lower level to prevent it from happening again.

Expectations (prognosis)

Some organs and tissues are more successfully transplanted than others. If rejection begins, immunosuppressive drugs may stop the rejection. The person must take immunosuppresive drugs for the rest of his or her life.

However, immunosuppressive treatment is not always successul.

Complications

     
  • Loss of function of the transplanted organ/tissue  
  • Infections (because the person’s immune system is constantly suppressed)  
  • Side effects of medications, which may be severe

Calling your health care provider
Call your health care provider if the transplanted organ or tissue does not seem to be working properly or if other symptoms occur. Also, call your health care provider if medication side effects develop.

Prevention
ABO blood typing and HLA (tissue antigen) typing before transplantation helps to ensure a close match. Suppressing the immune system is usually necessary for the rest of the transplant recipient’s life to prevent the tissue from being rejected in the future.

Johns Hopkins patient information

Last revised: December 5, 2012
by Potos A. Aagen, M.D.

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