Immune Rejection in Transplantation: Identifying

the Optimal Strategy for Long-Term Graft Survival

Introduction
In the new era of stem cell development, a wide range of potentials of SCs were
discovered making a clinical contribution to treat and regulate hundreds of diseases and
disorders. In neurological disorders, Alzheimer’s disease is one example of neurological
diseases that was regulated using NSCs for ex vivo delivery of protease genes as a treatment
for AD [1]. In addition to implications of cancer stem cells in types of cancer such as the
blood, breast, central nervous system, pancreas, skin, head and neck, colon, and prostate
[2]. In addition to many other diseases such as leukemia and T1D.

It is obvious that stem cell therapy is essential in treating and regulating various
diseases, however, immune rejection is one barrier against stem cell transplantation and,
therefore, it is necessary to find and justify the reason behind it to conduct an applicable
solution for it. But before discussing the cause of immune rejection or its mechanism,
transplantation methods should be mentioned first as it plays a crucial role in the process
of immune rejection.

There are two ways to transplant solid organs, Autologous and Allogeneic, or self and
non-self-transplantation, respectively. As normal, immune cells oversee preventing foreign
cells’ entrance to the body as they can pose a danger on it. So that in Autologous method,
immune system does not express any action towards the transplanted cells as they carry the
same genes that express receptors immune cells can identify. On the other hand, non-self-
transplantation causes the cell-identifying immune cells, T and B cells, to activate attack
protocol towards the foreign cells. So, it can be induced that Allogeneic transplantation is
the only method that can be exposed to immune rejection. But to fully understand how to
treat, or avoid, immune rejection, deeper details in the process must be investigated.

MHC, or Major Histocompatibility complex, is the protein family where antigens, the
protein in charge of recognizing other cells in the process of cell recognition, relevant to
transplantation belong to. MHC I, II, and III are the types of MHC molecules. MHC I contain
peptides of some pathogens so that they are responsible for the defense against infectious
disease. Recognition of peptide–MHC class I molecules on a cell result in CD8+ T cell killing
of that cell. MHC class II molecules are expressed only on specialized antigen-presenting
cells, such as dendritic cells, macrophages and B cells; presentation of non-self antigen on
MHC class II molecules leads to activation of CD4+ T helper cells. Both MHC class I, II are
relevant to the allorecognition, immune rejection. [3]

There have been many approaches to avoid immune rejection in many fields such as
pharmacology, cell biology and genetic engineering, and others. So, as there are many
methods used to reach one approach, it is necessary to put priorities to use the best method
in each patient’s condition.

Literature review
Recent studies investigated several ways of avoiding immune recognition including
immunosuppression drugs, HLA-matching, genetic engineered B cells, and using HSCT to
produce new immune system components beside immunosuppression drugs. These
methods showed a noticeable effectiveness in avoiding rejection. However, there was a lack
of knowledge of the priorities in which each method should be arranged according to its
effectiveness on recipients.

Novel immunosuppressive agents

Immunosuppressive agents are a primary method in avoiding immune responses against
grafting, transplanted, SC, tissue, or solid organ like kidney or liver. And here are some
examples of new immunosuppressive drugs.

Belatacept
Belatacept is a fusion protein, and an immunosuppressive drug used in post-kidney
transplantation, that binds the cytotoxic T lymphocyte antigen-4 (CTLA-4) to the Fc portion
of human IgG-1. It blocks T cells activation by binding to CD80/86 to inhibit them from
binding to CD 28 that is necessary to activate T cells. It is also used to inhibit CD80/CD86
and PDL-1/PDL-2 to get the same target. The drug was approved by the Food and Drug
Administration in 2011 for rejection prophylaxis in adult organ transplantation as it showed
an impressive result in a study on the 666 patients who underwent kidney transplantation
where the rate of death or graft loss was 43% less in the Belatacept group than in
cyclosporine-A group, another immunosuppressive drug. [4,5].

Belimumab
 Belimumab is a B lymphocyte stimulant (BLyS) inhibitor. BlyS plays a crucial role in
proliferating B cells, as a result, it causes apoptosis, decreases in circulation of B cell clones,
and blocks the conversion of B cells to plasma in the immune response. However, it has
several disadvantages including: the increased risk of infections because of injection of
Belimumab and other immunosuppressant that targets the B lymphocyte, Psychiatric
influences such as anxiety or depression, and the inability to inject living vaccines to patients
receiving Belimumab [5].

Siplizumab

It is an antibody that acts against CD2, which is responsible for the adhesion of T cells
to APC through the interaction with LFA-3 ligand. Binding between CD2 and LFA-3 ligand is
essential in T cells activation. Siplizumab has shown promising effects in preventing acute
kidney allograft rejection and treating acute graft host-host-disease [5].

Engineering of SC derived islets

It is a new method discovered in 2022 by Dario Gerace, Quan Zhou and others. This
method depends on genetically engineered SCs islets to be immune-evasive and immune-
tolerizing cells. It is divided into two pathways: Genetic Engineering for Immune Evasion and
Localized Immune Tolerance.

Genetic Engineering for Immune Evasion

In this pathway, SC-islets is modified to over express Programmed death ligand- 1,

which is responsible for interaction with the PD-1 receptor on immune cells, specifically T
cells, to block their activation. So, it was used to help SC evade the immune response
against transplanting it.

In addition, the SC-islets were also modified to express long-chain fusion of HLA-E,
which stops the activity of the natural killer (NK) cells. To increase the efficiency of this
method, both the methods in this pathway were combined to be more effective in evading
immune rejection.

Localized Immune Tolerance

In this pathway, scientists engineered SC-islets to secrete 3 main cytokines to employ

immune-tolerizing strategy, the cytokines are:
 1- Interleukin-10 (IL-10): this cytokine can suppress various immune responses by
downregulating inflammatory cytokine production and inhibiting the activation of
immune cells.

2- Transforming Growth Factor-beta (TGF-β): TGF-β induces the differentiation and

function of T cells which is important in immune responses against grafted SCs or
organs.

3- Modified IL-2 (IL-2 mutein): this cytokine promotes the expansion of (Tregs) or
regulatory T cells, which tolerate the foreign cells instead of destroying it by activating
effector T cells.

This method is so powerful as it doesn’t evade the immune rejection effectively only, but also
help to treat T1D as it is caused by and autoimmune disease as it has successfully reversed
diabetes and were able to resist immune rejection much longer than cells engineered with
immune evasion mechanisms alone [6].

Biomaterials for blocking immune recognition

Biomaterials have been used to physically separate donor cells from the host
immune system, most notably in mouse models of type 1 diabetes mellitus. The Edmonton
protocol for treatment for type I diabetes uses allogeneic cells rather than the technically
complicated procedure of trans planting the whole pancreas. Islets of Langerhans isolated
from donor pancreases are embolized into the hepatic portal circulation under immune
system suppression with tacrolimus and sirolimus, and with initial treatment using
daclizumab (which neutralizes the interleukin 2 receptor on T cells) [8,9]. Currently, 44% of
patients treated with the Edmonton protocol and its derivatives are insulin-independent
three years after transplantation. Researchers are now developing biomaterials-based
methods to achieve similar clinical outcomes with less immunosuppression. Encapsulation
of islets in hydrogels to restrict contact between donor islets and the host immune system
was first attempted in the early 1980s [7]. The pore size of the hydrogel was large enough to
allow diffusion of small molecules and signaling proteins, including insulin, but small
enough to block passage of antibodies, complement, host antigen-presenting cells (which
could collect antigen) or T cells (which could kill encapsulated host cells by cytolytic
mechanisms). In principle, encapsulation should reduce the need for immunosuppressive
drugs after transplantation of allogeneic or even xenogeneic islets. In one study, an
encapsulation approach restored normoglycemia for more than one year in mice with
autoimmune diabetes that were transplanted with xenogeneic adult porcine islets together
with CTLA4-Ig and anti-CD154 (CD40 ligand). A more sophisticated device, which contained
hydrogel-encapsulated islets within polymer film membranes, prevented rejection of
xenogeneic rat islets and restored normoglycemia in pigs with chemically induced diabetes
for more than two months with no chemical or biomolecular suppression of the immune
system. In those experiments, the eventual loss of glycemic control may have been due to
growth of the recipient animal but not of the donor islet mass, which suggests that the
duration of graft function could have been extended [5].

Methodology
In this paper, prospective cohort is followed as it aims to find the
differences between several methods or drugs that overcome the stem cell
rejection and indicate the long-term effects of each method or drug and finally
determine the most efficient ones.
The data is collected in the secondary way as the paper focuses on data
collected from other resources instead of conducting the data entire the
research itself. In addition, to collect data about the recent ways or methods
to avoid immune rejection, hundreds of experiments were done to test each
method’s efficiency in the labs.

Results
After discussing several methods of avoiding immune rejection either by pharmacology,
genetic engineering, biomaterials, and others, we concluded all the methods in one table
to analyze the advantages and disadvantages of each method and conduct the most, but
not the best as there is no perfect cure or drug for avoiding immune rejection, suitable and
safe method among all of them.
Method Types Pros cons
pharmacology Belatacept
- Blocks T cell activation, reducing rejection risk in kidney transplants.
- Binds more strongly to CD80/86 than abatacept, improving efficacy. -Associated with a higher risk of acute rejection and post-transplant lymphoproliferative disease (PTLD).
- Reduces the need for calcineurin inhibitors (which can be toxic). -Higher rates of EBV (Epstein-Barr virus) reactivation.
- Protects against chronic allograft nephropathy and maintains better GFR (glomerular filtration rate). -Requires intravenous administration, which may be less convenient.
- Does not require dose adjustments in kidney or liver failure. -Needs frequent dosing initially after transplant.
- Can be used both in induction and maintenance therapy after transplantation.

Belimumab -Targets and inhibits B-lymphocyte stimulator (BLyS), reducing B cell activation and
proliferation.
- Can cause hypersensitivity and infusion reactions, including anaphylaxis.
- Associated with psychiatric side effects like anxiety and depression.
- Shown to reduce the risk of developing donor-specific antibodies (DSAs), which can - Increases the risk of severe infections when combined with other B cell-targeting
therapies.
lead to graft dysfunction
- Not recommended with live vaccines, cyclophosphamide, or anti-CD20 therapies
- Does not increase the risk of infection significantly compared to placebo. due to higher infection risks.
- Used for patients with systemic lupus erythematosus and being explored for use in
solid organ transplantation.

- Blocks CD2 antigen, preventing T cell adhesion and activation, which helps reduce - Clinical data are still limited, so further research is needed to fully
Siplizumab rejection. understand its long-term benefits and risks.
- Has shown beneficial effects in preventing acute renal allograft rejection and treating
graft-versus-host disease (GVHD).
- Effectiveness and safety in broader clinical applications are not as
- Demonstrated potential as an induction agent for renal transplant patients. well established as with more commonly used agent
- Has an acceptable safety profile based on clinical studies.

- Reduced Immunosuppression: Encapsulation of donor islets in hydrogels can - Limited Longevity: Encapsulation devices can lose effectiveness over time, as
Biomaterials For blocking immune
recognition potentially reduce or eliminate the need for systemic immunosuppressive drugs, lowering
the risk of related side effects.
seen in experiments where glycemic control was lost, potentially due to factors like
recipient growth without corresponding growth of the islet mass.
- Selective Permeability: The hydrogels are designed with pore sizes that allow small - Incomplete Immune Protection: While encapsulation prevents direct immune cell
molecules like insulin to pass through while blocking larger immune system components contact, it may not entirely block immune system recognition or response,
(e.g., T cells, antibodies, and antigen-presenting cells), reducing the likelihood of especially over long periods.
immune-mediated rejection. - Size Limitations: The encapsulation material may limit the amount of islet tissue
- Improved Islet Survival: In mouse models, encapsulation has successfully prolonged that can be effectively transplanted, which may impact long-term function.
the survival and function of donor islets, even with xenogeneic transplants (e.g., porcine - Complexity of Materials: Developing effective biomaterials that balance diffusion,
islets). immune protection, and biocompatibility can be technically challenging.
- Long-Term Function: Some studies demonstrated normoglycemia for over a year in
autoimmune diabetic mice, with protection from immune rejection.

- Reduced Immune Rejection: By overexpressing PD-L1 and HLA-E, this method directly
Engineering of SC Genetic Engineering - Limited Longevity: Despite the immune evasion, the transplanted cells can still be rejected over time,
as seen in xenotransplantation models, where the cells were rejected within 10 days.
for Immune Evasion inhibits the immune system's ability to attack the transplanted stem cell-derived islets,
- Species-Specific Issues: The effectiveness of PD-L1 and HLA-E can vary across species, making it
derived islets reducing the risk of rejection.
- T-Cell Inactivation: PD-L1 blocks the activation of T cells, which are crucial players in
challenging to translate results from animal models to humans, as interactions like PD -L1/PD-1 may
differ.
immune rejection, effectively suppressing the body's immune response against the - Partial Protection: While immune evasion provides some protection, it may not be enough to fully
prevent immune responses, especially in more complex immune environments like
transplant.
xenotransplantation.
- Natural Killer (NK) Cell Suppression: The expression of HLA-E inhibits NK cells, adding - Complexity of Genetic Modifications: The process of genetically modifying cells to express PD-L1 and
another layer of protection for the transplanted cells. HLA-E is technically complex, increasing production costs and making it less accessible for widespread
- Increased Efficiency: Combining PD-L1 and HLA-E expression provides a more clinical use.
- Risk of Immune Suppression: Overexpression of PD-L1 may lead to over-suppression of the immune
comprehensive immune evasion strategy, making it more effective than using one
system, potentially allowing cancerous cells to evade immune surveillance or increasing the risk of
method alone. infections.
- No Need for Systemic Immunosuppression: By genetically modifying the cells to avoid
immune detection, this method minimizes the need for systemic immunosuppressive
drugs, reducing the associated risks of infections and long-term toxicity.

Localized - Long-Term Graft Survival: By secreting immune-modulatory cytokines (IL-10, TGF-β, and
IL-2 mutein), this method promotes longer-term survival of transplanted cells by actively
- Risk of Chronic Immunosuppression: The continuous secretion of immune-modulatory cytokines may
result in chronic local immunosuppression, potentially allowing infections or abnormal cells to persist

Immune suppressing immune attacks.

near the graft.
- Cytokine Imbalance: Excessive levels of IL-10, TGF-β, or IL-2 mutein could lead to over-suppression of
- Localized Effect: The immune tolerance is localized to the transplant site, reducing the
Tolerance need for systemic immunosuppression and minimizing the risk of broader immune
the immune system locally, potentially causing undesired effects on surrounding tissue.
- Limited Duration: While more durable than immune evasion alone, the effectiveness may diminish
over time, especially as cytokine production could decline or immune tolerance mechanisms wear off.
suppression.
- Complex Engineering and Delivery: The process of engineering cells to secrete multiple cytokines in
- Expansion of Regulatory T Cells (Tregs): The secretion of IL-2 mutein selectively precise amounts is technically challenging and increases production complexity.
promotes Treg expansion, helping to maintain immune tolerance and prevent graft - Potential for Off-Target Effects: Although the approach is localized, there's still a risk that the cytokines
rejection. could diffuse beyond the target area, affecting other parts of the immune system and potentially leading
to unintended immune suppression elsewhere.
- Reduced Inflammation: IL-10 and TGF-β help downregulate inflammatory responses,
- Unclear Long-Term Outcomes: The long-term impact of sustained cytokine production and Treg
creating a favorable environment for the transplant to thrive without immune interference. expansion on overall immune function, especially in a human clinical setting, is not fully understood.
- Dual Benefit for Autoimmune Diseases: This method not only protects the graft but also
addresses underlying autoimmune issues (like in type 1 diabetes) by modulating the
immune system.
- Minimal Systemic Side Effects: Since the immune tolerance is localized, there’s less
risk of systemic immune suppression, reducing the chance of opportunistic infections or
cancer.
Conclusion

Overall, by analyzing the data collected in the table above, it is conducted that for long-term graft
survival and safety Localized Immune Tolerance is the most suitable method in genetic
engineering of SC-islets, however, it is recently discovered and all the aspects and insights around
this new method. As it is promising and holds expected great potential in the immune rejection
avoidance, but it is still under development.

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