Matching for the non-conventional MHC-I MICA gene significantly reduces the incidence of acute and chronic GVHD

Graft-versus-host disease (GVHD) is among the most challenging complications in unrelated donor hematopoietic cell transplantation (HCT). The highly polymorphic "MHC class I chain-related gene A", MICA, encodes a stress-induced glycoprotein expressed primarily on epithelia. MICA interacts with the invariant activating receptor NKG2D; expressed by cytotoxic lymphocytes. The MICA gene is located in the MHC, next to HLA-B; hence MICA has the requisite attributes of a bona fide transplantation antigen. Using high-resolution sequence-based genotyping of MICA, we retrospectively analyzed the clinical impact of MICA mismatches in a multicenter cohort of 922 unrelated donor HLA-A, -B, -C, -DRB1, and -DQB1 10/10 allele-matched HCT. Among the 922 pairs, 113 (12.3%) were mismatched in MICA MICA mismatches were significantly associated with an increased incidence of grade III-IV acute GVHD (HR, 1.83; 95% CI, 1.50 to 2.23; P<0.001), chronic GVHD (HR, 1.50; 95% CI, 1.45 to 1.55; P<0.001) and non-relapse mortality (HR, 1.35; 95% CI, 1.24 to 1.46; P<0.001). The increased risk of GVHD was mirrored by a lower risk of relapse (HR, 0.50; 95% CI, 0.43 to 0.59; P<0.001), indicating a possible graft-versus-leukemia effect. In conclusion, when possible, selecting a MICA-matched donor significantly influences key clinical outcomes of HCT in which a marked reduction of GVHD is paramount. The tight linkage disequilibrium between MICA and HLA-B renders identifying a MICA-matched donor readily feasible in clinical practice.