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Case Reports
. 2025 Nov;86(6):111606.
doi: 10.1016/j.humimm.2025.111606. Epub 2025 Oct 27.

Kidney transplant rejection despite zero eplet DR / DQ mismatch: A case report

A Quintiliano  1 , C H Cramer  2 , A J Bentall  3 , M Prieto  4 , S H Nasr  5 , C A Schinstock  3 , M J Gandhi  6
Affiliations
Case Reports

Kidney transplant rejection despite zero eplet DR / DQ mismatch: A case report

A Quintiliano et al. Hum Immunol. 2025 Nov.

Abstract

Eplet mismatch (MM) quantification is a valuable tool for refining histocompatibility in kidney transplantation, especially at HLA-DR/DQ loci. However, zero MM at these loci does not ensure complete immunological safety. We report a 17-year-old male who received a living donor kidney transplant via the kidney paired donation (KPD) program. The donor had 0 eplet MMs at HLA-DR/DQ, with negative crossmatch and no pre-transplant donor-specific antibodies (DSAs). Despite this, the patient developed early mixed rejection-T cell-mediated (TCMR) and antibody-mediated (ABMR), and further analysis revealed DSAs targeting an HLA-C 80 K/77 N eplet. Combined treatment for TCMR and ABMR led to histological and functional improvement. This case illustrates the limitation of relying solely on HLA-DR/DQ eplet matching. Despite achieving 0 MM at these loci, the patient developed significant alloimmune injury. Molecular MM scores are useful predictive biomarkers, but they do not fully capture the complexity of immune responses in transplantation.

Keywords: Antibody-mediated rejection; Eplet mismatch; Kidney transplantation; Low risk.

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Conflict of interest statement

Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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