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However, despite their popularity, it remains unclear how accurately TWAS recover the true direction of a gene\u2019s effect on a trait. Here we estimate the false sign rate of TWAS for plasma proteins, leveraging the expectation that increased gene expression should generally increase protein expression. We then extend this framework to complex traits, where loss-of-function burden tests provide the expected direction of effect. In both analyses, we observe high discordance with expectations, with TWAS showing a false sign rate of 23% for plasma proteins and 33% for complex traits. We propose that much of the sign discordance arises when expression quantitative trait loci in non-trait-relevant tissues tag haplotypes associated with traits in genome-wide association studies via distinct, tightly linked regulatory variants, yielding spurious TWAS associations with the correct genes but with unreliable direction of effect. These findings show that TWAS-based direction-of-effect estimates should be interpreted with caution and raise concerns about the reliability of TWAS more broadly.<\/jats:p>","DOI":"10.1038\/s41588-026-02796-4","type":"journal-article","created":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T09:02:19Z","timestamp":1792659739000},"page":"3004-3012","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["High false sign rates in transcriptome-wide association studies"],"prefix":"10.1038","volume":"58","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-7108-0026","authenticated-orcid":false,"given":"Peter A.","family":"Gerlach","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7975-247X","authenticated-orcid":false,"given":"Nikhil","family":"Milind","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3199-1447","authenticated-orcid":false,"given":"Jeffrey P.","family":"Spence","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8828-5236","authenticated-orcid":false,"given":"Jonathan K.","family":"Pritchard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,10,22]]},"reference":[{"key":"2796_CR1","doi-asserted-by":"publisher","first-page":"245","DOI":"10.1038\/ng.3506","volume":"48","author":"A Gusev","year":"2016","unstructured":"Gusev, A. et al. 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