Abstract

Bulk analysis of renal allograft biopsies (rBx) identified RNA transcripts associated with acute cellular rejection (ACR); however, these lacked cellular context critical to mechanistic understanding. We performed combined single cell RNA transcriptomic and TCR/{beta} sequencing on rBx from patients with ACR under differing immunosuppression (IS): tacrolimus, iscalimab, and belatacept. TCR analysis revealed a highly restricted CD8+ T cell clonal expansion (CD8EXP), independent of HLA mismatch or IS type. Subcloning of TCR/{beta} cDNAs from CD8EXP into Jurkat76 cells (TCR-/-) conferred alloreactivity by mixed lymphocyte reaction. scRNAseq analysis of CD8EXP revealed effector, memory, and exhausted phenotypes that were influenced by IS type. Successful anti-rejection treatment decreased, but did not eliminate, CD8EXP, while CD8EXP were maintained during treatment-refractory rejection. Finally, most rBx-derived CD8EXP were also observed in matching urine samples. Overall, our data define the clonal CD8+ T cell response to ACR, providing novel insights to improve detection, assessment, and treatment of rejection.