• Clinical science



Transplantation is the process of transferring an organ or a part thereof (known as a graft) from one donor to him/herself (autologous transplantation) or to another recipient (allogenous transplantation if the individuals are not identical twins). In addition to being subject to strict legal requirements, the donor and recipient must be histocompatible in allogenous transplantations in order to minimize the risk of transplant rejection. Because the major histocompatibility complex (MHC) is only perfectly matched in isotransplantation (involving the transfer of genetically identical tissue, e.g., from an identical twin), allogenous transplantation subsequently requires immunosuppressive therapy.

Transplantation biology

Transplant immunology

Major histocompatibility complex (MHC) and human leukocyte antigen (HLA)


Prerequisites for organ matching

Rh compatibility is not required for solid organ transplantation. Both Rh compatibility and ABO compatibility are not essential for hematopoietic stem cell transplantation!

Types of graft based on histocompatibility between donor and recipient
Type Definition Examples
  • Graft originates from the recipient
  • Graft originates from a genetically identical person (identical twin)
  • Graft originates from a genetically different person
  • Graft originates from a different species (e.g., pig)

Immunosuppressive therapy is not required for autograft transplantation.


Solid organ transplantation

Organ procurement

Post-transplant immunosuppressive therapy

Immunosuppressive therapy is a balancing act: Too much immunosuppression, and the risk of infection increases. Too little, and the risk of rejection increases!


Renal transplantation

Renal transplantation is superior to dialysis in end-stage renal disease (ESRD)!


Liver transplantation


Cardiac transplantation


Hematopoietic stem cell transplantation

Types of HSCT

Autologous stem cell transplantation Allogenous stem cell transplantation
  • To allow the administration of higher doses of antineoplastic therapy than would otherwise be possible for certain non-hematological malignancies (e.g., germ cell tumors, soft tissue sarcoma)
  • Multiple myeloma
  • Lymphoma


The mortality rate of allogenous stem cell transplantation is declining, but is still as high as 50%!



Graft-related complications

Graft rejection

  • Definition: graft failure as a result of damage to the graft by the host's immune response
Types of graft rejection
Hyperacute rejection Acute rejection Chronic rejection
  • < 1% of post-transplant organ dysfunction
  • Causes approx. 50% of post-transplant organ dysfunction
  • Causes approx. 50% of post-transplant organ dysfunction
  • < 48 hours after transplantation (usually within minutes to hours)
  • < 6 months after transplantation (usually within days to weeks)
  • > 6 months after transplantation (usually after a few years)
Risk factors
Clinical findings
  • Intraoperative assessment: swelling of the organ as soon as perfusion is restored
  • Slow, progressive loss of organ function
  • Biopsy: small vessel thrombosis and graft infarction
  • Preoperative cross-matching and ABO grouping
  • Irreversible process with no known prevention
  • Graft removal
  • Graft removal

Graft rejection manifests as a failure of the transplanted organ and is very difficult to distinguish from other post-transplant complications. A biopsy is required to confirm the diagnosis.

Graft-versus-host disease (GvHD)

Acute GvHD Chronic GvHD
  • < 100 days after transplantation
  • > 100 days after transplantation
  • Mostly unknown
Clinical presentation

The skin, intestines, and liver are the most commonly affected organs in GvHD.

Immunosuppression-related complications

Post-transplant infections


Early onset

(< 1 month after transplantation)

Late onset 1–6 months
6–12 months
> 12 months

Prevention of post-transplant infections

Because the symptoms of CMV infections can appear similar to those of transplant rejection, differentiating between conditions can be tricky!

Post-transplant malignancy


We list the most important complications. The selection is not exhaustive.

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last updated 10/31/2020
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