Histopathological analysis of infiltrating T cell subsets in acute T cell-mediated rejection in the kidney transplant

Table 1 Baseline clinical and demographic characteristics of the kidney transplant patients

Characteristic	n3	No rejection	n4	ATCMR	P value
Age (yr)1	7	60.8	14	44.9	0.0101
Male sex (%)	7	57.14	14	71.43	0.6384
Race Chinese (%)	7	86.71	14	57.14	0.3371
Dialysis vintage (yr)1	7	2.08	14	5.015	0.6888
Transplant vintage (yr)1	7	13.75	14	3.935	0.0031
Deceased donor (%)	6	66.67	13	53.85	> 0.9999
Delayed graft function (%)	6	33.33	12	41.67	> 0.9999
Cold ischaemia time (h)	5	3	9	10	0.6973
Total HLA mismatch (#)1	6	3	11	3	0.9973
Very high immune risk (%)2	6	16.67	11	43.45	0.3334
% Panel of reactive antibodies1	3	8	9	0	0.2318
History of ATCMR (%)	7	14.29	14	50	0.1736
Re-transplant (%)	7	0	14	7.14	> 0.9999
GFR at biopsy (mL/min per 1.73 m2)1	7	41.2	14	17.95	0.0767
Proteinuria at biopsy (g/d)1	7	3.5	14	1.23	0.2028
t score1	7	0	14	2	0.0116
I score1	7	1	14	2	0.0007
v score1	7	0	14	0	0.1196
Tacrolimus use at biopsy (%)	7	0	14	50	0.0468
Ciclosporin use at biopsy (%)	7	100	14	35.71	0.0071
MTORI use at biopsy (%)	7	0	14	14.29	0.5333
Steroids use at biopsy (%)	7	100	14	100	> 0.9999
Mycophenolate use at biopsy (%)	7	57.14	14	85.71	0.28
Azathioprine use at biopsy (%)	7	28.57	14	0	0.10
Anti-CD25 induction (%)	5	0	12	41.67	0.2445
Prior thymoglobulin use (%)	7	14.29	14	14.29	> 0.9999

¹Results reported as median values;

²According to United Kingdom Fuggle’s classification based on HLA-DRB1 and HLA-B mismatches[30];

³Indicates the number of patients with available data in the non-rejection group;

⁴Indicates the number of patients with available data in the ATCMR-KTx group. ATCMR: Acute T cell-mediated rejection; GFR: Glomerular filtration rate; HLA: Human leukocyte antigen; MTORI: Mammalian target of rapamycin inhibitor.

Table 2 Baseline clinical and demographic characteristics of the kidney transplant patients

Patient	Group	Age	Sex	Race	Dialysis vintage (yr)	Tx vintage (yr)	Donor type	DGF	CIT (h)	HLA MM (#)	Immune risk	PRA (%)	ATCMR Hx	Re-Tx	Anti-CD25 induction	ATG use	Immuno-suppression at Bx
1	ATCMR	49.9	M	Ma	0.36	14.26	Living	No	0	0	Low	UNK	Yes	No	No	No	CsA + MPA
2	ATCMR	32.1	F	Ch	0.38	0.17	Living	No	UNK	1	Very high	20	Yes	No	Yes	No	MTORI + MPA
3	ATCMR	25.7	M	Ma	1.21	6.80	UNK	UNK	UNK	UNK	UNK	UNK	Yes	No	UNK	No	Tac + MPA
4	ATCMR	36.7	M	Ma	9.48	0.45	Deceased	Yes	10	3	High	7	Yes	No	Yes	No	Tac + MPA
5	ATCMR	59.4	M	Ch	8.68	3.90	Deceased	No	9	4	Very high	7	Yes	No	Yes	No	CsA + MPA
6	ATCMR	46.0	F	Ch	1.20	2.34	Living	No	0	1	Moderate	0	No	No	Yes	No	CsA + MPA
7	ATCMR	40.6	M	Ch	0.31	1.03	Living	No	UNK	UNK	UNK	UNK	No	No	No	Yes	Tac + MPA
8	ATCMR	44.1	M	Ch	9.52	8.09	Deceased	Yes	23	2	High	0	Yes	Yes	No	Yes	Tac
9	ATCMR	56.9	M	Ch	7.98	13.8	Deceased	Yes	UNK	3	High	UNK	No	No	No	No	CsA + MPA
10	ATCMR	45.6	M	Ch	1.08	1.26	Living	UNK	UNK	UNK	UNK	UNK	No	No	UNK	No	Tac + MPA
11	ATCMR	51.5	M	In	8.29	5.34	Deceased	No	19	4	Very high	0	Yes	No	No	No	Tac + MPA
12	ATCMR	57.4	F	Ma	9.31	2.38	Deceased	Yes	15	3	High	0	No	No	Yes	No	Tac + MPA
13	ATCMR	43.6	M	Ch	8.87	3.97	Deceased	Yes	14	5	Very high	3	No	No	No	No	CsA
14	ATCMR	30.6	F	Ma	2.05	11.86	Living	No	5	2	Very high	0	No	No	No	No	MTORI + MPA
15	NR	51.9	M	Ch	0.65	13.75	Living	No	0	4	High	UNK	No	No	No	Yes	CsA + MPA
16	NR	65.1	M	Ch	2.08	18.21	Living	No	UNK	0	Low	UNK	No	No	UNK	No	CsA + MPA
17	NR	61.9	M	Ch	5.88	10.31	Deceased	No	3	3	High	8	No	No	No	No	CsA
18	NR	64.4	F	Ch	2.03	18.36	Deceased	No	16	1	Moderate	33	Yes	No	No	No	CsA + AZA
19	NR	51.0	M	Ch	1.44	11.34	UNK	UNK	UNK	UNK	UNK	UNK	No	No	UNK	No	CsA + MPA
20	NR	43.6	F	Ch	3.24	19.81	Deceased	Yes	1.2	3	High	UNK	No	No	No	No	CsA + AZA
21	NR	60.8	F	Ma	4.42	8.86	Deceased	Yes	18	4	Very high	0	No	No	No	No	CsA + MPA

ATCMR: Acute T cell-mediated rejection; ATG: Anti-thymocyte globulin; AZA: Azathioprine; Bx: Biopsy; Ch: Chinese; CIT: Cold ischaemia time; CsA: Ciclosporin; DGF: Delayed graft function; F: Female; HLA: Human leukocyte antigen; Hx: History; In: Indian; M: Male; Ma: Malay; MM: Mismatch; MPA: Mycophenolic acid analogue; MTORI: Mammalian target of rapamycin inhibitor; NR: No rejection; PRA: Panel of reactive antibodies; Tac: Tacrolimus; Tx: Transplant; UNK: Data unknown.

Table 3 Immune infiltrate characteristics and outcomes of the kidney transplant patients

Pati-ent	Group	t	i	v	CD4 (%)	CD8 (%)	CD19 (%)	Granzyme B (cells/mm2)	IL-17 (cells/mm2)	Foxp3 (cells/mm2)	CTL/Treg ratio	Th17/Treg ratio	GFR at Bx	GFR last follow-up	Protei-nuria at Bx	Protei-nuria last follow-up	Time to any rejection (d)	Time to doubling of creatinine (d)	Time to Tx loss (d)	Total follow-up (d)
1	ATCMR	1	3	1	35	25	15	68	5	35	2	0.1	18.5	4.7	4.28	UNK	NA	38	116	116
2	ATCMR	3	2	0	60	60	10	346	2	149	2.3	0	33.6	67.2	0.51	0.16	28	NA	NA	1643
3	ATCMR	2	2	1	30	35	30	31	15	73	0.4	0.2	48.1	30.9	0	UNK	92	NA	NA	1623
4	ATCMR	2	2	0	30	25	30	55	17	56	1	0.3	15.2	9.5	0.41	1.71	NA	NA	513	513
5	ATCMR	3	2	1	85	80	25	544	19	311	1.8	0.1	11.2	15	1.08	1.61	NA	NA	645	645
6	ATCMR	2	1	0	30	15	10	26	52	3	8.8	17.9	30.1	6.7	0.39	UNK	1037	941	1176	1176
7	ATCMR	0	1	1	10	20	10	42	4	6	6.6	0.6	49.8	70.3	0.32	0.09	NA	NA	NA	1327
8	ATCMR	0	2	1	5	10	0	13	0	8	1.5	0	16.9	6.2	2.43	6.66	164	164	164	164
9	ATCMR	2	2	0	10	5	10	4	43	1	4.4	47.4	17.4	14.3	2.34	UNK	NA	NA	759	759
10	ATCMR	1	2	0	35	50	15	81	20	17	4.7	1.2	25.8	8.6	1.53	2.46	404	911	933	933
11	ATCMR	1	1	1	10	5	5	9	22	2	4.7	11.5	112.1	44.7	2.07	0.07	NA	520	NA	950
12	ATCMR	1	2	0	20	15	10	18	5	4	4.8	1.3	16.4	15.1	0.58	UNK	NA	NA	NA	917
13	ATCMR	3	2	0	80	70	20	322	32	35	9.3	0.9	9.2	9.2	1.39	1.39	NA	NA	NA	1
14	ATCMR	2	2	0	20	10	10	38	62	10	3.9	6.3	15.2	8.2	6.09	UNK	NA	NA	NA	913
15	NR	0	1	0	20	15	10	36	55	34	1	1.6	21.1	8.8	6.77	UNK	NA	598	862	862
16	NR	0	1	0	5	10	10	1	5	2	0.5	2.5	43.4	35.8	0.13	1.2	NA	NA	NA	1507
17	NR	0	1	0	5	15	10	5	15	4	1.3	3.8	41.2	63.5	0.39	0.57	NA	NA	NA	1306
18	NR	1	1	0	35	30	30	92	16	32	2.8	0.5	56	9.8	2.4	2.24	NA	974	1118	1118
19	NR	0	1	0	0	5	0	21	2	8	2.7	0.2	64.6	53.2	3.62	7.57	1168	NA	NA	1173
20	NR	1	0	0	20	15	10	25	73	15	1.7	5	28.4	7.1	3.5	UNK	NA	188	520	520
21	NR	1	1	0	25	15	10	81	81	10	8.1	8.1	20.9	12.4	10.59	7.46	NA	141	163	163

ATCMR: Acute T cell-mediated rejection; Bx: Biopsy; GFR: Glomerular filtration rate; HLA: Human leukocyte antigen; i: i score; NA: Not applicable; NR: No rejection; t: t score; Tx: Transplant; UNK: Data unknown; v: v score.

Table 4 Correlation (R) between numbers and ratios of infiltrating immune cells and kidney transplant outcomes

Group	Immune parameter	vs	Outcome	R	P value
No rejection	Infiltrating Th17 cells		Creatinine t3	0.9429	0.0167
No rejection	Infiltrating Th17 cells		GFR t0	-0.8571	0.0238
No rejection	Infiltrating Th17/Tregs		GFR t0	-0.7857	0.048
No rejection	Infiltrating Th17 cells		GFR t3	-0.9429	0.0167
No rejection	Infiltrating Th17/Tregs		GFR t3	-0.9429	0.0167
No rejection	Infiltrating Th17 cells		GFR t6	-0.8929	0.0123
ATCMR-KTx	Infiltrating CTL/Tregs		Creatinine t3	-0.6694	0.0145
ATCMR-KTx	Infiltrating Th17 cells		Creatinine t24	0.6485	0.049
ATCMR-KTx	Infiltrating Th17 cells		Creatinine t30	0.7619	0.0368
ATCMR-KTx	Infiltrating Th17 cells		GFR t30	-0.8333	0.0154
ATCMR-KTx	Infiltrating Th17 cells		Proteinuria t12	0.8095	0.0218

ATCMR-KTx: Acute T cell-mediated rejection in the kidney transplant; GFR: Glomerular filtration rate.

Table 5 Comparison of time to transplant outcomes in the kidney transplant patients

Outcomes	Group	Median time-to-event	P values
Any rejection	ATCMR	1037	0.0941
	No rejection	Undefined1
Doubling of creatinine	ATCMR	941	0.7452
	No rejection	974
Transplant loss	ATCMR	1176	0.956
	No rejection	1118

¹Median time-to-event was not obtainable (see Figure 4A). ATCMR: Acute T cell-mediated rejection.

Table 6 Effect of immune and clinical variables on kidney transplant outcomes

Outcomes	Risk factor	HR	95%CI	P value
Time to any rejection	Age	0.898	0.821, 0.983	0.0193
Time to doubling of creatinine	Infiltrating Th17 cells	1.031	1.002, 1.061	0.0359
Time to doubling of creatinine	Proteinuria	1.382	1.087, 1.757	0.0083
Time to transplant loss	Infiltrating Th17 cells	1.026	1.000, 1.052	0.0472
Time to transplant loss	Serum creatinine	1.009	1.003, 1.016	0.0036
Time to transplant loss	Delayed graft function	5.456	1.238, 24.036	0.0160