Transplant tolerance

Acute cellular rejection involves infiltration of macrophages and lymphocytes into the graft and is evident from the necrosis of the parenchymal cells of the graft. The lysis of the parenchymal cells of the transplanted tissue is achieved by the infiltrating leukocytes. Acute cellular rejection may be the product of several mechanisms including cytolytic T-cell-mediated lysis, NK cell-mediated lysis and activated macrophage-mediated lysis. The acute cellular rejection predominantly involves CD8+ T cytolytic cells that kill the grafted tissue. 

In some cases, a slow rejection phase begins many months or even years after transplantation when acute rejection has subsided. The chronic rejection appears to be due to the slow buildup of antibodies against the graft antigens and/or due to cell-mediated immune responses by the recipient. It does not respond well to the immunosuppressive drugs, and a new transplant is needed following chronic rejection reaction. 

Fibrosis resulting in the loss of normal organ structures is the hallmark of chronic rejection. The fibrosis may be due to wound healing, which is then followed by the cellular necrosis of acute rejection. However, it must be pointed out that chronic rejection develops many times in the absence of acute rejection. Fibrosis may be a result of several diverse factors such as equation of chronic rejection with chronic delayed-type hypersensitivity reaction, injury to blood vessels and resulting response to chronic ischemia, the proliferation of smooth muscle cells in the intima of arterial walls producing vascular occlusion, or persistent viral infections that will induce cellular immune response. 

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