Immunological reactions of interest in the transplant setting include Tolerance, Accommodation and Rejection.
Tolerance refers to a state of sustained non immune responsiveness to alloantigens. Tolerance is different from Accommodation, which refers to s state of resistance to immune damage. A state of Tolerance remains a goal for solid organ transplantation as it would allow for the withdrawal of immunosuppressive regimes and their associated toxic effect to grafts.
Accommodation permits patients to maintain grafts even in the presence of Donor Specific Antibodies (DSA). Accommodation was originally identified in ABO blood group incompatible renal transplantation in which the graft survived and functioned normally despite the presence in the patient of high titre ABO blood group antibodies. Proposed mechanisms for Accommodation include the expression in the graft of several protective genes which block the activation of the transcription factor NF-KB, thereby suppressing induction of proinflammatory genes and inhibition of the membrane attack complex thereby disrupting the action of complement.
Immune mechanisms which contribute to graft rejection include acute and chronic alloantibody mediated rejection (AMR) as well as acute and chronic cellular rejection.
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