Book Review

Pathology and Immunology of Transplantation and Rejection

N Engl J Med 2001; 344:1953-1954June 21, 2001

Article

Pathology and Immunology of Transplantation and Rejection
Edited by Sathia Thiru and Herman Waldmann. 583 pp., illustrated. Malden, Mass., Blackwell Science, 2001. $250. ISBN: 0-632-03676-1

The importance of pathology and immunology in transplantation is increasing with the widespread use of organ and tissue transplantation for the treatment of end-stage diseases. Recently, the end points for clinical trials in organ transplantation have been based on pathology, not graft failure. Many immunosuppressive drugs in development are based on molecules in the immune system itself. There is a need for material that makes this fast-moving area of science accessible to students, trainees, and physicians in practice. Pathology and Immunology of Transplantation and Rejection provides an overview of many areas of the field — to which a number of the authors have made important contributions — from a European perspective.

The book opens with a discussion of the basic science of transplantation immunology and of immunosuppression in chapters 1 through 6. In these chapters we find the immunobiology of graft rejection, histocompatibility antigens, methods of tissue typing, the blood-transfusion effect, and the actions of immunosuppressive agents. The immune response to xenotransplants is covered in chapter 7, which explains the basis for the use of grafts from transgenic animals carrying complement regulator genes to reduce destruction of the xenograft.

The focus then shifts to clinical transplantation, with a discussion of immunosuppression in renal transplantation, followed by a series of overviews of the clinical pathology of kidney, liver, heart, lung, and pancreas and islet transplants. The one page of color pictures of the lesions of a rejected liver graft is particularly welcome. The pathology of cornea and skin transplantation is described, and there is a brief discussion of graft-versus-host disease. Finally, chapters 16 to 19 discuss aspects of infectious diseases in transplant recipients, organized according to organ rather than infectious agent.

The book suffers from the usual multiauthor problems of excess coverage of some topics (e.g., an entire chapter on the blood-transfusion effect) and duplication and underrepresentation of others (e.g., introductory discussions of immunosuppressive agents in chapters 5 and 7 and inadequate discussion of chemokines, signaling by cytokine receptors, programmed cell death, the pathology of graft-versus-host disease, and targets of immunosuppressive drugs). The chapter on the pathology of renal transplants should have included the details of the various classifications of transplant lesions, particularly the Banff scheme. Considering the relatively small role of the blood-transfusion effect, it is peculiar to devote a whole chapter to it and only a few paragraphs each to the mechanisms of action of cyclosporine, tacrolimus, mycophenolic acid, and sirolimus. Perhaps a more global view of infectious diseases in transplant recipients would have presented more details about major problems such as hepatitis C and Epstein–Barr virus, with less repetition.

I would recommend that transplantation professionals buy this book, and I will refer to it when I review certain subjects, particularly for its exhaustive reference lists. The book is well written, and some chapters are excellent. The strength of the book is in the selection of knowledgeable authors who write well. Trainees will find the early chapters to be good introductions to transplantation immunology, and the clinical chapters provide an overview of the pathology of specific organs. Thus, a resident rotating to a transplantation service could find individual chapters quite useful.

The two principal problems of the book are its delayed publication and its paucity of illustrations, particularly color illustrations. The reference lists are exhaustive but generally end in 1997; the book would have been well received then but will have less of an effect in 2001. Many chapters would benefit from more illustrations. For example, one chapter of 23 pages has only one table and no figures. There are no pictures of the molecular structures of the major immunosuppressive drugs and few representations of their sites of action. However, many contemporary reviews of immunosuppressive drugs are available to supplement these discussions.

The book illustrates the turmoil and challenges in medical publication. The possibilities of rapid electronic publication and access to images have raised the bar for authors, editors, and publishers. Books must be affordable but still have abundant color images, diagrams, and cartoons. Readers in the field would welcome Web-based electronic publications that allow them to download the key material and the reference lists. And the information must be timely. The authors are authorities who worked hard to create chapters that were valuable in 1997 and that should have been available to their audience before 2001. The challenge is to get such material into the hands of the readers within months of its submission. Ideally, authors should be able to update their publications continually, creating “living books” that will remain useful for many years. Perhaps full exploitation of the potential of the Internet can provide answers to these challenges.

Philip Halloran, M.D., Ph.D.
University of Alberta, Edmonton, AB T6G 2S2, Canada