Donor HLA class 1 evolutionary divergence and late allograft rejection after liver transplantation in children: an emulated target trial.

HLA evolutionary divergence (HED), a continuous metric quantifying the differences between each amino acid of two homologous HLA alleles, reflects the importance of the immunopeptidome presented to T lymphocytes. It has been associated with rejection after liver transplantation. This retrospective cohort study aimed to analyze the potential effect of donor or recipient HED on liver transplant rejection in a new series of patients transplanted during childhood and followed in adulthood. The study included 120 children who had been transplanted between 1991 and 2010 and were followed by routine biopsies and histological evaluations with a median of 14.1 years post-LT. Liver biopsies were performed routinely 1, 5, 10 and 20 years after transplantation and in the event of liver dysfunction. HED was calculated using the physicochemical Grantham distance for donor and recipient class I (HLA-A, -B, -C) and class II (HLA-DRB1, -DQB1) alleles. The influence of HED on rejection was analyzed using IPW and target trial emulation using the g method. Based on the IPW score, donor HED class I was correlated with the occurrence of late (>90 days) rejection (HR, 1.19, 95% CI: 1.01-1.40) independently of HLA mismatches, donor age and initial induction. This emulated target trial confirmed that donor HED class I has a causal effect on liver graft rejection and this relationship was observed long-term.