American Journal of Kidney Diseases

Association of Predicted HLA T-Cell Epitope Targets and T-Cell–Mediated Rejection After Kidney Transplantation

      Rationale & Objective

      The relationship between human leukocyte antigen (HLA) molecular mismatches and T-cell–mediated rejection (TCMR) is unknown. We investigated the associations between the different donor HLA–derived T-cell targets and the occurrence of TCMR and borderline histologic changes suggestive of TCMR after kidney transplantation.

      Study Design

      Retrospective cohort study.

      Setting & Participants

      All kidney transplant recipients at a single center between 2004 and 2013 with available biopsy data and a DNA sample for high-resolution HLA donor/recipient typing (N = 893).


      Scores calculated by the HLA matching algorithm PIRCHE-II and HLA eplet mismatches.


      TCMR, borderline changes suggestive of TCMR, and allograft failure.

      Analytical Approach

      Multivariable cause-specific hazards models were fit to characterize the association between HLA epitopes targets and study outcomes.


      We found 277 patients developed TCMR, and 134 developed only borderline changes suggestive of TCMR on at least 1 biopsy. In multivariable analyses, only the PIRCHE-II scores for HLA-DRB1 and HLA-DQB1 were independently associated with the occurrence of TCMR and with allograft failure; this was not the case for HLA class I molecules. If restricted to rejection episodes within the first 3 months after transplantation, only the T-cell epitope targets originating from the donor’s HLA-DRB1 and HLA-DQB1, but not class I molecules, were associated with the early acute TCMR. Also, the median PIRCHE-II score for HLA class II was statistically different between the patients with TCMR compared to the patients without TCMR (129 [IQR, 60-240] vs 201 [IQR, 96-298], respectively; P < 0.0001). These differences were not observed for class I PIRCHE-II scores.


      Observational clinical data and residual confounding.


      In the absence of HLA-DSA, HLA class II but not class I mismatches are associated with early episodes of acute TCMR and allograft failure. This suggests that current immunosuppressive therapies are largely able to abort the most deleterious HLA class I–directed alloimmune processes; however, alloresponses against HLA-DRB1 and HLA-DQB1 molecular mismatches remain insufficiently suppressed.

      Plain-Language Summary

      Genetic differences in the human leukocyte antigen (HLA) complex between kidney transplant donors and recipients play a central role in T-cell–mediated rejection (TCMR), which can lead to failure of the transplanted kidney. Evaluating this genetic disparity (mismatch) in the HLA complex at the molecular (epitope) level could contribute to better prediction of the immune response to the donor organ posttransplantation. We investigated the associations of the different donor HLA–derived T-cell epitope targets and scores obtained from virtual crossmatch algorithms with the occurrence of TCMR, borderline TCMR, and graft failure after kidney transplantation after taking into account the influence of donor-specific anti-HLA antibodies. This study illustrates the greater importance of the molecular mismatches in class II molecules compared to class I HLA molecules.

      Graphical abstract

      Index Words

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      Linked Article

      • Molecular Mismatch and the Risk for T Cell–Mediated Rejection
        American Journal of Kidney DiseasesVol. 80Issue 6
        • Preview
          T cell–mediated rejection (TCMR) is evidence of alloimmune reactivity characterized by inflammation within the tubules, interstitial space, and/or arterial intima and media in kidney transplantation. Risk factors for TCMR include younger recipient age, delayed graft function, inadequate immunosuppression, and HLA mismatch.1-6 Advances in genetics and 3-dimensional modeling have led to a renaissance in human leukocyte antigen (HLA) mismatch assessment through the evaluation of such mismatches at the molecular level.
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