Tolerance-inducing strategies in transplantation surgery—current status and perspectives

Life-long immunosuppressive medication has to be administered to the majority of solid-organ recipients after transplantation of genetically mismatched organs in order to circumvent acute graft loss due to alloreactive rejection responses triggered by the host's immune system. However, life-long suppression of the immune system implicitly limits the host's ability to respond appropriately to infectious, fungal and carcinogenic threats. Simultaneously non-targeted inhibition of immunological defense mechanisms coincides with substantial morbidity and mortality for the host. Thus, for the past five decades research in the field of transplantation medicine has focused on innovative strategies to induce graft tolerance to donor alloantigens, a state in which the recipient's lymphocytes have learned to accept the foreign organ or tissue as "self" or "non-dangerous" without the need of chronic immunosuppression. Achieving that specific goal of donor-specific tolerance would not only minimize the risk of the recipient to suffer from serious side effects resulting from continuous immunosuppressive therapy, but would also prevent loss of long-term graft function caused by chronic rejection processes. Recently, numerous insights into the dynamic interrelationships of host immune responses elicited by donor antigen-presentation, either on the graft itself or on specialized antigen-presenting cells, have substantially broadened our understanding of the cascade of events that result in the acquisition of tolerance.

We highlight areas of research that are currently particularly helpful not only to set up new strategies to induce donor-specific tolerance or long-term graft acceptance, but also to identify and describe parameters which serve to characterize those patients who have acquired a state of tolerance and are safe to be weaned off from their immunosuppressive regimen.