HLA-B*
39 risk has been well defined in the literature [
3,
4,
7,
8]. With the characterisation of conserved extended haplotypes in type 1 diabetes risk [
18,
23], studies exploring the genetic context of
HLA-B*
39 alleles (via haplotype and SNP analysis) have become increasingly important in further characterising haplotypic risk for type 1 diabetes and those MHC regions involved in risk determination [
4,
24,
25]. Here we confirm previously discovered haplotypic associations of
HLA-B*
39 alleles, and place these associations in the context of high-density SNP analysis.
B*
3906 is associated with increased risk on
DRB1*
0801-
DQB1*
0402 and
DRB1*
0101-
DQB1*
0501 haplotypes, whereas
B*
3901 is associated with increased risk on
DRB1*
1601-
DQB1*
0502 haplotypes. While both
B*
39 alleles are associated with increased risk,
B*
1402, their nearest non-
B*
39 HLA-B allele by amino acid sequence, is not associated with increased risk [
22]. Even one amino acid difference, particularly in the peptide-binding region, could influence disease risk associated with the allele. Therefore, even though there are only seven amino acid differences (five in the peptide-binding region) between
B*
1402 and
B*
3906, those changes could result in the drastic difference in risk seen in this analysis. In addition, as there are two amino acid differences between
B*
3906 and
B*
3901, both in the peptide-binding region, those differences could also result in differences in disease risk. Therefore, we hypothesise that
B*
39-associated increased risk is due to the differences in amino acid sequence between
B*
3901/
B*
3906 and
B*
1402 or that the risk is associated with polymorphisms where
B*
3906 and
B*
3901 are congruent for almost all SNPs but do not match the
B*
1402 SNP haplotype. Gene-conversion events between alleles of the
HLA-B gene have been reported previously. This is one possible explanation for the presence of highly similar SNP sequences surrounding the
HLA-B gene for the
B*
3906,
B*
3901 and
B*
1402 alleles [
26–
28].
There are five genes in the 142,861 base pair region of near SNP identity between the B*3906 and B*3901 haplotypes: HLA-B, DHFRP2 (dihydrofolate reductase pseudogene 2), HLA-S (pseudogene), MICA (MHC class I polypeptide-related sequence A), and HLA-X (pseudogene). Theoretically, any of these genes or even variations in non-coding sequence in the region could contribute to the increased risk associated with B*3901 and B*3906.
There are limitations to this work. First,
B*
39 is not a common allele, as we see it in only 3% of individuals with type 1 diabetes in this dataset. Consequently, we cannot tell whether
B*
3906 haplotypes confer greater risk than
B*
3901 haplotypes as the only
HLA-DR/DQ haplotype that is common to both alleles is
DRB1*
0101-
DQB1*
0501, and the numbers in this group are too small to distinguish the risk associated with the alleles. Therefore, a larger dataset is needed to fully differentiate the risk associated with these two
B*
39 alleles. It has been previously described that the
B*
3906 allele is high risk on the
DRB1*
0404-
DQB1*
0302 haplotype [
8,
29,
30]. Our results are in the same direction, but a larger dataset would be needed to confirm the effect (
DRB1*
0404-
DQB1*
0302: 9/9
B*
3906 [100% of
B*
3906 are case chromosomes] compared with 249/304 non-
B*
3906 [82% of non-
B*
3906 are case chromosomes],
p
=

0.4, OR 4.2).
We did not observe a difference in risk due to the
B*
3906 allele on the
DRB1*
0401-
DQB1*
0302 haplotype (
DRB1*
0401-
DQB1*
0302: 17/19
B*
3906 [89% of
B*
3906 are case chromosomes] compared with 1034/1134 non-
B*
3906 [91% of non-
B*
3906 are case chromosomes],
p
=

0.7, OR 0.82). It is possible that the
DRB1*
0401-
DQB1*
0302 risk is so high that we are unable to see an incremental effect from
B*
3906. In addition, as the numbers in the
B*
3906-
DRB1*
0401-
DQB1*
0302 group are small, it is possible that the study was underpowered to find an association. Similarly, the
B*
3901 allele is rare (1.2%). The current study should be considered hypothesis-generating given the limited number of chromosomes containing
B*
39, even in this large T1DGC dataset.
To replicate our findings from the T1DGC dataset we employed a large, publicly available dataset from the Wellcome Trust Case Consortium (WTCCC) [
5] (ESM Table
2). Diplotypes containing high-risk
DRB1-DQB1 haplotypes (namely
DRB1*
0801-
DQB1*
0402,
DRB1*
0101-
DQB1*
0501,
DRB1*
301-
DQB1*
0302,
DRB1*
0401-
DQB1*
0302, and
DRB1*
1601-
DQB1*
0502) were evaluated for the presence of
HLA-B*
3906 and
HLA-B*
3901. Those containing
DRB1*
0801-
DQB1*
0402 (but not the other high-risk haplotypes) were more likely to have
HLA-B*
3906 (case 42% [8/19], control 6% [3/53],
p
=

6.3

×

10
−4, OR 12). Similar results were found for genotypes containing
DRB1*
0101-
DQB1*
0501 (case 9% [7/81], control 2% [7/367],
p
=

5.8

×

10
−3, OR 5) and
DRB1*
0301-
DQB1*
0201 (case 5% [25/502], control 1% [9/628],
p
=

6.7

×

10
−4, OR 4). Our finding that the haplotype
DRB1*
0401-
DQB1*0302 is not associated with
HLA-B*
3906 was also confirmed, with similar frequency between cases (3% [5/181]) and controls (2% [3/186],
p
=

0.5).
Our analyses using both the T1DGC and WTCCC datasets, therefore, indicate that HLA-B*3906 is high risk on specific DRB1-DQB1 haplotypes. At a practical level, identifying specific HLA-DR/DQ haplotypes also carrying B*39 will aid type 1 diabetes genetic prediction for individuals, particularly in a research setting. In terms of quantificative risk and application in a clinical setting, genotypes (i.e. diplotypes or both HLA haplotypes) are critical determinates, especially such high-risk diplotypes as DR3/4 with HLA-B*3906. In that the B*39 alleles are uncommon among patients with type 1 diabetes, identifying B*39 alleles will have little impact on the prediction of overall risk of type 1 diabetes (as illustrated by an ROC curve). In particular, absence of a B*39 allele would not appreciably decrease the overall risk of type 1 diabetes. In contrast the very high odds ratios of B*39 in combination with specific HLA-DR/DQ alleles (e.g. DRB1*0801-DQB1*0402) indicate that for individuals carrying these genotypes there would be a potentially important increase in risk with the presence of B*39. Absolute diabetes risk of genotype DRB1*08-B*39/DRB1*03 is estimated to be 5%, compared with 0.26% when B*39 is not present with this same genotype. This 5% risk for the DRB1*08-B*39/DRB1*03 genotype is comparable with the risk seen with the highest risk genotype DR3/4.
From a theoretical point of view, if the effects of B*39 alleles are dependent on both specific HLA-DR/DQ haplotypes and in particular the specific B*39 sequences, it suggests a potentially complex model of pathogenesis. The leading hypothesis is that B*39 alleles present specific islet peptides to CD8 T lymphocytes. HLA-DR/DQ alleles might determine CD4 T cells targeting of specific autoantigens and B*39 alleles would then enhance CD8 T cells targeting of peptides of these autoantigens. Alternatively it is possible that class I polymorphisms may even influence thymic selection and the repertoire of CD4 T cell receptors. Understanding the mechanism by which B*39 alleles enhance diabetes risk on specific HLA-DR/DQ haplotypes will likely contribute to our overall understanding of the loss of tolerance leading to type 1 diabetes.