Table Of ContentHLA FROM
BENCHTOP TO
BEDSIDE
ARTHUR BRADLEY EISENBREY, III, MD, P D
H
Associate Professor of Pathology,
Wayne State University School of Medicine,
Detroit, MI, United States;
Clinical Associate Professor of Pathology,
University of Toledo College of
Medicine and Life Sciences,
Toledo, OH, United States
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Preface
Understanding human histocompatibility is a challenge. Those of us who
have been immersed in this study for decades marvel at the changes that
have takenplace intechnology, the incrediblediversity packedinto a short
stretch of the human genome, and the breadth of human health that is
touched by studies in what is now known as immunogenetics. For years,
those of us who teach fellows, residents, and technologists what we do in
our “HLA labs” have relied on some excellent guides for introduction
to the field: Marsh, Parham and Barber’s excellent The HLA FactsBook,
Academic Press, 2000, and Rodey’s foundational HLA Beyond Tears:
Introduction to Human Histocompatibility, second edition, Pel-Freez, 2000.
There are many excellent review articles and textbook chapters which can
provide overviews of this complex and evolving field and many will be
cited in this book. Much, however, has changed since the publication of
“Beyond Tears” and the “Facts Book.”
This book is built on a broad foundation that began when I was a
research technicianfor George C.Lakatos,MD,in theresearch labsrun by
Daisy McCann, PhD, at Wayne County General Hospital, Wayne,
Michigan. Herta Vickery, PhD, stepped me through a crossmatch for a
kidneytransplantinlate1973orearly1974.Asayoungresearchtechnician
doing cancer immunotherapy research in mice, this looked like an exciting
application of the immunology that I was learning. In retrospect, thecrude
agglutination of buffy coat cells from the peripheral blood of the donor
with the serum of the proposed recipient was not as sophisticated as the
Ouchterlony double immunodiffusion I was using for antibody detection
and quantification.
The intent of this book is to provide a picture of where HLA or his-
tocompatibility testing is four decades after my introduction to the field.
Whether you are a casual reader or a student/technologist/resident/fellow
trying to get a “quick understanding” of HLA, I hope that this will be an
acceptable starting point for your learning. There will be a little history to
putthingsinperspective,andtheneachchapterwillfocusononeclinically
relevant subject area.
This isnot a reference guidefor all of the testing that maybeperformed
in HLA testing laboratories, whether named HLA, Immunogenetics, or
TransplantImmunologyasmypreviouslabswerenamed.Somelaboratories
ix
x Preface
performinfectiousdiseasetestingfororgandonors,somelaboratoriesperform
(cid:1)
non-HLA crossmatches (e.g., XM-ONE , AbSorber AB, Stockholm,
Sweden),andmanylaboratoriesthatsupporthematopoieticstemcelltrans-
plantationperformengraftmentmonitoring.Mostofthesesubjects,although
relatedtotransplantationarenotHLAorMajorHistocompatibilityComplex
(MHC) testing and are not covered in this text. Engraftment monitoring,
althoughnotHLAtesting,iscoveredinChapter10becauseofitsimportance
inhematopoieticstemcelltransplantation.
Thereferencesarecitedforthemoreseriousstudentofimmunogenetics
toprovidemoredepthandtogiverecognitiontothosewhosefoundational
work made this effort possible. I also recognize those who have taught me,
mentored me, and challenged me as teachers, colleagues, supervisors, staff,
resources, and friends.
This book is dedicated to the patients and donors who make trans-
plantation a reality and to those nontransplant patients with other health
issues whom we serve. Thank you for every encounter that provides a
learning opportunity.
References to commercial products are not given as endorsements
and are included only for informational purposes. The author has received
no financial support or incentive from any vendor or supplier of clinical
laboratory reagents or instrumentation.
Acknowledgments
I am eternally in debt to all of the scientists, physicians, technologists,
nurses,andpatientswhohaveguidedmygrowthasascientistandphysician
studying and practicing within the broad field of immunology, particularly
Daisy McCann, PhD, Herta Vickery, PhD, William S. Moore, PhD,
Gerald Gleich, MD, C. Garrison Fathman, MD, Richard Walker, MD,
Dorothy Levis, MT(ASCP), Sharon Skorupski, BS(CHS), all of my
researchcollaborators,andmywife,LouiseM.Eisenbrey,MS,MT(ASCP),
CQM/OE(ASQ). I mark a particular note of thanks to my colleague,
friend, and editor, John Gerlach, PhD, for his review, editorial comments,
suggestions, and recommended changes.
In my interactions with medical students, residents, friends, colleagues,
and family, I have found a tendency to “Google-it” when looking up
medical information. I would like to counter that tendency with the
admonitiontotaketheextrastepandusePubMed.gov(https://www.ncbi.
nlm.nih.gov/pubmed/)andothergovernmentandnoncommercialsources
formedicalandscientificinformationwheneverpossible.Thisbookwould
not have been possible without PubMed and the exquisite services pro-
videdbythereferencelibrariansandeJournalaccessattheVeraP.Shiffman
Medical Library, Wayne State University, Detroit, MI.
xi
CHAPTER 1
Introduction and some history
Contents
Fundamentals:innate andadaptiveimmunity 2
References 4
Bullet points
1. The primary human histocompatibility antigens are called human
leukocyte antigens (HLAs).
2. HLA is part of the human major histocompatibility complex (MHC)
located on the short arm of chromosome six.
3. Understanding of the human histocompatibility system has been
evolving for 60years and continues to evolve.
Let us get something out of the way, right up front: HLA is used as an
acronym for human leukocyte antigen. HLA is also used as shorthand for
the system of genes that code for and control the cell markers and recog-
nition system that prevent cells and tissues from one individual from
engraftinginanother,evencloselyrelated,individual.Amorepropername
is the human major histocompatibility complex (MHC) for the very
complex region on the short arm of chromosome six (6p21.31). There is
much more in the MHC than genes that code for histocompatibility
antigens.Aswewillsee,later,HLA/MHCgenesdomuchmorethanmake
it difficult to transplant organs and stem cells.
ThenameforthesystemdidnotstartasHLA.PhysicianandscientistDr.
Jean-Baptiste-Gabriel-Joachim Dausset (Nobel Prize in Physiology or Medicine,
1980) gets credit for recognizing the existence of the new antigen system
whichwouldbecomeknownasHLA.Hisinitialworkwasonantibodiesin
patients with leucopenia (Dausset and Nenna, 1953). He realized that there
was a pattern of reactivity consistent with alloantibodies (Dausset, 1958;
Carosella,2009).RosePayne,JJvanRood,andotherswerealsoworkingon
“leukoagglutinins” and had presented at conferences, but Dausset published
first (Emanuel Hackel, Ph.D., personal communication).
Dausset’s MAC antigen was named from the initials of the three donors
whosewhitebloodcellsdidnotreactwiththeleukoagglutinatingantibodieshe
HLAfromBenchtoptoBedside
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2 HLAfromBenchtoptoBedside
was investigating (The antigen he named MAC eventually was renamed
HLA-A2). Naming of the new antigen system was entirely by local
conventions, and each of the labs investigating “leukoagglutinins” had
their own names for the antigens they described. Efforts at colla-
boration between laboratories led to an ongoing series of workshops
and conferences (http://www.ihwg.org/about/history.html and http://
hla.alleles.org/nomenclature/workshops.html). At the Third Conference on
HistocompatibilityTesting,July1967(Amos,1968),theparticipantstookthe
existingandcompetingnamingsystems(FOUR,Hu,Du,LA,TO,andLC)
and agreed that the first major locus recognized would benamed HL-A (an
apparent contraction of Hu and LA). When it later became apparent that
another genetic locus was present, the system was renamed HLA, and the
newlyidentifiedlociwerenamedHLA-AandHLA-B,respectively.Antigens
were named with sequential numbers, the naming convention that remains
today(http://hla.alleles.org)(Robinsonetal.,2015;Marshetal.,2010).
Note: Much of the structure, function, and genetics of the human
MHC was predicted from decades of work with laboratory animals,
particularly mice. Knowledge of the mouse MHC (H-2) has been, and
remains,foundationalforunderstandingofthehumanMHC(Penn,2002).
For students of the history of science and medicine, I recommend the
very readable historical reviews of the development of the knowledge of
the MHC system and HLA by Thorsby (2009) and Terasaki (2007).
References for the exciting history of molecular testing and HLA will be
provided in Chapters 7 and 8.
Fundamentals: innate and adaptive immunity
Some basic knowledge of the human immune system is needed to
understand HLA. There are two broad groups of immune cells in all
vertebrates, including Homo sapiens: innate immunity and adaptive immu-
nity.Thecellsoftheinnateimmunitysystemarepresumedtohaveevolved
firstbecausethefunctionsaresharedacrossphyla.Generallyspeaking,these
cells function by phagocytosis and internal lysis of pathogens or by direct
cell to cell killing through the release of cytotoxins. The cells of adaptive
immunity are shared by all vertebrates and include the two broad classes of
lymphocytes (T cells and B cells), specialized proteins called immuno-
globulins (membrane-bound and secreted products of B cells and their
derivative plasma cells), T cell receptors (TCR), and antigen presentation
by two classes of specialized membrane-bound proteins of the MHC
Introductionandsomehistory 3
(Parham, 2005). The advanced and flexible functions of the adaptive
immune system often rely on interactions with the cells of the innate
immune system, particularly circulating mononuclear phagocytic cells and
more sessile dendritic phagocytic cells.
Histocompatibility and immunity involve far more than the genes
present intheMHC.Although I(semijokingly)tellstudents, residents,and
fellows that, “The short arm of chromosome six is the most important part
of the human genome,” the MHC does not and cannot function without
the rest of the immune system. Some critical systems that will be
encountered in this book (and your other reading) are the TCR alpha and
deltagenes(chromosome14q),TCRgamma(chromosome7p),TCRbeta
(7q), immunoglobulin heavy chain genes (IGH; 14q), and the immuno-
globulin light chains (kappa: 2p; lambda: 22q). There are cosignals,
hormones, receptors, binding proteins, ligands, stabilizing protein struc-
tures, signaling peptides, and enzymes which have critical roles and will be
discussed in the context of MHC-related activities.
The cellular components of human immunity are well described in
hematology textbooks, textbooks of general immunology, and in online
resources. The critical cells for the functions of the human MHC are
lymphocytes (adaptive immunity) and the circulating and sessile mono-
nuclear macrophages (innate immunity) which present antigen (“antigen
presentingcells”orAPCs)tothelymphocytes(antigenpresentationwillbe
described later). Lymphocytes are divided in two broad classes, T cells
(T lymphocytes) and B cells (B lymphocytes). T cells were named for
thymus-derived lymphocytes because immature or “naive” T cells were
initially shown to mature in the thymus (a lymphoid tissue located in the
anteriormediastinum)(Waldmann,1979).Bcellswerenamedforthebursa
of Fabricius, a gut-associated lymphoid tissue of birds, which was found to
be the primary source of lymphoid cells that produce antibody (Glick,
1991). Other cell types and subtypes will be introduced as needed to
describe functions related to the MHC and HLA in particular.
The following chapters in this book present broad concepts: genetics
and structure, antibody detection and identification, HLA “typing” solid
organ transplantation, stem cell transplantation, transfusion medicine
support, and disease association/pharmacogenetics. Each topic will be
presentedwithhistoricalbackgroundsothatthecurrentmethodologiescan
be seen in perspective of the changes in technology for those who have
never had the experience of using the older techniques.
4 HLAfromBenchtoptoBedside
References
Alleles.http://hla.alleles.org/nomenclature/workshops.html.
Amos,D.B.,1968.Humanhistocompatibility locusHL-A.Science 159,659e660.
Carosella, E.D., 2009. From MAC to HLA. Professor Jean Dausset, the pioneer. Hum.
Immunol. 70,661e662.
Dausset, J.,1958.Iso-leuco-anticorps. ActaHaematol. 20,156e166.
Dausset,J.,Nenna,A.,1953.Présenced’uneleucoagglutininedanstroisserumsdemaladies
leucopéniques. Sang24,410e417.
Glick, B., 1991. Historical perspective; the bursa of Fabricius and its influence on B-cell
development, pastandpresent. Vet.Immunol.Immunopathol.30,3e12.
Hla.http://hla.alleles.org.
Hwg.http://www.ihwg.org/about/history.html.
Marsh, S.G.E., Albert, E.D., Bodmer, W.F., Bontrop, R.E., Dupont, B., Erlich, H.A.,
Fernández-Vina, M., Geraghty, D.E., Holdsworth, R., Hurley, C.K., Lau, M.,
Lee, K.W., Mach, B., Mayr, W.R., Maiers, M., Müller, C.R., Parham, P.,
Petersdorf, E.W., Sasazuki, T., Strominger, J.L., Svejgaard, A., Terasaki, P.I.,
Tiercy,J.M.,Trowsdale,J.,2010.NomenclatureforfactorsoftheHLAsystem.Tissue
Antigens 75,291e455.
Parham,P.,2005.MHCclassImoleculesandKIRsinhumanhistory,healthandsurvival.
Nat.Rev. Immunol.5,201e214.
Penn, D.J.,2002. Major histocompatibility complex(MHC). In: eLS.John Wiley &Sons
Ltd,Chichester.http://www.els.net.
Robinson, J., Halliwell, J.A., Hayhurst, J.H., Flicek, P., Parham, P., Marsh, S.G.E., 2015.
The IPD and IMGT/HLA database: allele variant databases. Nucleic Acids Res. 43,
D423eD431.
Terasaki,P.,2007. Abriefhistory ofHLA.Immunol.Res. 38,139e148.
Thorsby,E.,2009. Ashorthistory of HLA.TissueAntigens74,10e116.
Waldmann, H., 1979. Interactions between T and B cells: a review. J. R. Soc. Med. 72,
198e202.
CHAPTER 2
The structure of the major
histocompatibility complex and
major HLA components
Contents
HLAclass I 8
FunctionofHLAClass Iamolecules 9
HLAIbmolecules 13
OtherHLAclass Ihistocompatibility genes:MICAandMICB 13
HLAclass II 14
References 19
Bullet points
1. The human major histocompatibility complex (MHC) contains the
human leukocyte antigen (HLA) gene loci.
2. ClassIalociarecalled“Classical”HLAloci(HLA-A,HLA-B,HLA-C).
3. Class Ia proteins are constitutively expressed on the surface of all nucle-
ated cells.
4. Class Ib proteins have restricted tissue distribution and limited antigen-
presenting repertoires.
5. Class II proteins (HLA-DR, HLA-DQ, and HLA-DP) are primarily
expressed on the surface of antigen-presenting cells and are inducible
on other nucleated cells.
6. Class I proteins present cytosolic self-antigens to CD8 T cells.
7. Class II proteins present external (cell environment) antigens to CD4
T cells.
Thehumanmajorhistocompatibilitycomplex(MHC)islocatedonthe
shortarmofchromosomesixat6p21.31(Fig.1).TheMHCwasoneofthe
first regions of the human genome that was completely sequenced and
remains the most gene-dense region of the human genome identified and
sequenced (The MHC sequencing consortium, 1999;Horton et al.,2004).
ThesizeandextentoftheMHChasundergoneanumberofrevisionsfrom
theearlylinkagemaps(Carrolletal.,1987).Sequencingdata(Hortonetal.,
2004) extended both the functional associations and size of the complex
HLAfromBenchtoptoBedside
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