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Gupta G, Athreya A, Kataria A. Biomarkers in Kidney Transplantation: A Rapidly Evolving Landscape. Transplantation 2024:00007890-990000000-00820. [PMID: 39020463 DOI: 10.1097/tp.0000000000005122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
The last decade has seen an explosion in clinical research focusing on the use of noninvasive biomarkers in kidney transplantation. Much of the published literature focuses on donor-derived cell-free DNA (dd-cfDNA). Although initially studied as a noninvasive means of identifying acute rejection, it is now clear that dd-cfDNA is more appropriately described as a marker of severe injury and irrespective of the etiology, elevated dd-cfDNA ≥0.5% portends worse graft outcomes. Blood gene expression profiling is also commercially available and has mostly been studied in the context of early identification of subclinical rejection, although additional data is needed to validate these findings. Torque teno virus, a ubiquitous DNA virus, has emerged as a biomarker of immunosuppression exposure as peripheral blood Torque teno virus copy numbers might mirror the intensity of host immunosuppression. Urinary chemokine tests including C-X-C motif chemokine ligand 9 and C-X-C motif chemokine ligand 10 have recently been assessed in large clinical trials and hold promising potential for early diagnosis of both subclinical and acute rejection, as well as, for long-term prognosis. Urinary cellular messenger RNA and exosome vesicular RNA based studies require additional validation. Although current data does not lend itself to conclusion, future studies on multimodality testing may reveal the utility of serial surveillance for individualization of immunosuppression and identify windows of opportunity to intervene early and before the irreversible allograft injury sets in.
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Affiliation(s)
- Gaurav Gupta
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA
| | - Akshay Athreya
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA
| | - Ashish Kataria
- Division of Nephrology, Medical College of Georgia, Augusta, GA
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2
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Sinha R, Zhu Z, Park S, Rebello C, Kinsella B, Friedewald J, Kleiboeker S. Combined Metagenomic Viral Detection and Donor-Derived Cell-Free DNA Quantification in Plasma From Kidney Transplant Recipients. Transplant Proc 2024:S0041-1345(24)00348-8. [PMID: 38972761 DOI: 10.1016/j.transproceed.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/27/2024] [Accepted: 06/07/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Kidney transplant recipients require potent immunosuppression and are predisposed to opportunistic infections, many of which have a viral etiology. Currently, viral assays detect and quantify single pathogens using PCR or qPCR. An unbiased sequencing method with comparable accuracy would allow simultaneous monitoring of multiple viral pathogens and nonpathogenic Anelloviridae. The quantification of donor-derived cell-free DNA (dd-cfDNA) is an established method for the detection of allograft rejection, and a single workflow combining dd-cfDNA quantification and viral detection represents an opportunity to improve patient monitoring and management. METHODS Whole genome sequencing of cell-free DNA was performed using 1,980 plasma samples from 256 subjects enrolled in a multi-center study. Non-human sequences underwent reference-assisted assembly and taxonomic annotation of the viral DNA pathogens. RESULTS Of the 1,980 samples tested, 1,453 (73.4%) had ≥1 viral detection(s), either a known viral pathogen or torque teno virus (TTV), with positivity rates generally declining 12-18 months post-transplant. Concordance of metagenomic NGS (mNGS) viral detection with qPCR detection was 97.7% (94.1% sensitivity, 98.2% specificity), and a linear relationship was demonstrated between mNGS viral quantitation and qPCR results. BK virus, cytomegalovirus, and Epstein-Barr virus were detected by sequencing up to 60 days prior to independently established clinical diagnoses. CONCLUSIONS Whole-genome sequencing allows simultaneous quantification of dd-cfDNA as well as sensitive and early detection of viral infection through secondary analysis of the same sequencing results. In combination with dd-cfDNA, mNGS viral detection may provide additional pathogen surveillance results and serve as a useful biomarker for both over- and under-immunosuppression.
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Affiliation(s)
- Rohita Sinha
- Eurofins Viracor Clinical Diagnostics, Lenexa, Kansas
| | - Zixuan Zhu
- Eurofins Viracor Clinical Diagnostics, Lenexa, Kansas
| | - Sookhyeon Park
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | | | - Bradley Kinsella
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - John Friedewald
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
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3
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Nast CC. Polyomavirus nephropathy: diagnosis, histologic features, and differentiation from acute rejection. CLINICAL TRANSPLANTATION AND RESEARCH 2024; 38:71-89. [PMID: 38725187 PMCID: PMC11228385 DOI: 10.4285/ctr.24.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/28/2024] [Accepted: 03/20/2024] [Indexed: 06/29/2024]
Abstract
Polyomaviruses, particularly BK virus, are ubiquitous latent infections that may reactivate with immunosuppression during kidney transplantation, resulting in polyomavirus nephropathy (PVN). The levels of viruria and viremia serve as tools for screening and making a presumptive diagnosis of PVN, respectively, while a definitive diagnosis requires a kidney biopsy. There are histologic classifications of PVN based on the extent of tubular cell viral infection, interstitial fibrosis, and interstitial inflammation. These classifications correlate to some degree with graft function and loss, aiding in determining treatment efficacy and prognostication. PVN has histologic overlap with acute cell-mediated rejection, making the differential diagnosis challenging, although there are suggestive features for these different causes of graft dysfunction. This article reviews the diagnosis, histologic findings, and classifications of PVN, and discusses how to differentiate viral nephropathy from acute rejection.
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Affiliation(s)
- Cynthia C Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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4
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Kotton CN, Kamar N, Wojciechowski D, Eder M, Hopfer H, Randhawa P, Sester M, Comoli P, Tedesco Silva H, Knoll G, Brennan DC, Trofe-Clark J, Pape L, Axelrod D, Kiberd B, Wong G, Hirsch HH. The Second International Consensus Guidelines on the Management of BK Polyomavirus in Kidney Transplantation. Transplantation 2024:00007890-990000000-00727. [PMID: 38605438 DOI: 10.1097/tp.0000000000004976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
BK polyomavirus (BKPyV) remains a significant challenge after kidney transplantation. International experts reviewed current evidence and updated recommendations according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Risk factors for BKPyV-DNAemia and biopsy-proven BKPyV-nephropathy include recipient older age, male sex, donor BKPyV-viruria, BKPyV-seropositive donor/-seronegative recipient, tacrolimus, acute rejection, and higher steroid exposure. To facilitate early intervention with limited allograft damage, all kidney transplant recipients should be screened monthly for plasma BKPyV-DNAemia loads until month 9, then every 3 mo until 2 y posttransplant (3 y for children). In resource-limited settings, urine cytology screening at similar time points can exclude BKPyV-nephropathy, and testing for plasma BKPyV-DNAemia when decoy cells are detectable. For patients with BKPyV-DNAemia loads persisting >1000 copies/mL, or exceeding 10 000 copies/mL (or equivalent), or with biopsy-proven BKPyV-nephropathy, immunosuppression should be reduced according to predefined steps targeting antiproliferative drugs, calcineurin inhibitors, or both. In adults without graft dysfunction, kidney allograft biopsy is not required unless the immunological risk is high. For children with persisting BKPyV-DNAemia, allograft biopsy may be considered even without graft dysfunction. Allograft biopsies should be interpreted in the context of all clinical and laboratory findings, including plasma BKPyV-DNAemia. Immunohistochemistry is preferred for diagnosing biopsy-proven BKPyV-nephropathy. Routine screening using the proposed strategies is cost-effective, improves clinical outcomes and quality of life. Kidney retransplantation subsequent to BKPyV-nephropathy is feasible in otherwise eligible recipients if BKPyV-DNAemia is undetectable; routine graft nephrectomy is not recommended. Current studies do not support the usage of leflunomide, cidofovir, quinolones, or IVIGs. Patients considered for experimental treatments (antivirals, vaccines, neutralizing antibodies, and adoptive T cells) should be enrolled in clinical trials.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases Unit, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University Paul Sabatier, Toulouse, France
| | - David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Helmut Hopfer
- Division of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Parmjeet Randhawa
- Division of Transplantation Pathology, The Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Patrizia Comoli
- Cell Factory and Pediatric Hematology/Oncology Unit, Department of Mother and Child Health, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Helio Tedesco Silva
- Division of Nephrology, Hospital do Rim, Fundação Oswaldo Ramos, Paulista School of Medicine, Federal University of São Paulo, Brazil
| | - Greg Knoll
- Department of Medicine (Nephrology), University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Jennifer Trofe-Clark
- Renal-Electrolyte Hypertension Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
- Transplantation Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Lars Pape
- Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - David Axelrod
- Kidney, Pancreas, and Living Donor Transplant Programs at University of Iowa, Iowa City, IA
| | - Bryce Kiberd
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Hans H Hirsch
- Division of Transplantation and Clinical Virology, Department of Biomedicine, Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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5
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Hirschhorn JW, Sasaki MM, Kegl A, Akter T, Dickerson T, Narlieva M, Nhan N, Liu T, Jim P, Young S, Orner E, Thwe P, Lucic D, Goldstein DY. Performance evaluation of the high-throughput quantitative Alinity m BK virus assay. J Clin Microbiol 2024; 62:e0135423. [PMID: 38526061 PMCID: PMC11005350 DOI: 10.1128/jcm.01354-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/02/2024] [Indexed: 03/26/2024] Open
Abstract
BK virus (BKV) infection or reactivation in immunocompromised individuals can lead to adverse health consequences including BKV-associated nephropathy (BKVAN) in kidney transplant patients and BKV-associated hemorrhagic cystitis (BKV-HC) in allogeneic hematopoietic stem cell transplant recipients. Monitoring BKV viral load plays an important role in post-transplant patient care. This study evaluates the performance of the Alinity m BKV Investigational Use Only (IUO) assay. The linearity of the Alinity m BKV IUO assay had a correlation coefficient of 1.000 and precision of SD ≤ 0.25 Log IU/mL for all panel members tested (2.0-7.3 Log IU/mL). Detection rate at 50 IU/mL was 100%. Clinical plasma specimens tested comparing Alinity m BKV IUO to ELITech MGB Alert BKV lab-developed test (LDT) on the Abbott m2000 platform using specimen extraction protocols for DNA or total nucleic acid (TNA) resulted in coefficient of correlation of 0.900 and 0.963, respectively, and mean bias of 0.03 and -0.54 Log IU/mL, respectively. Alinity m BKV IUO compared with Altona RealStar BKV and Roche cobas BKV assays demonstrated coefficient of correlation of 0.941 and 0.980, respectively, and mean bias of -0.47 and -0.31 Log IU/mL, respectively. Urine specimens tested on Alintiy m BKV IUO and ELITech BKV LDT using TNA specimen extraction had a coefficient of correlation of 0.917 and mean bias of 0.29 Log IU/mL. The Alinity m BKV IUO assay was performed with high precision across the dynamic range and correlated well with other available BKV assays. IMPORTANCE BK virus (BKV) in transplant patients can lead to adverse health consequences. Viral load monitoring is important in post-transplant patient care. This study evaluates the Alinity m BKV assay with currently available assays.
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Affiliation(s)
- Julie W. Hirschhorn
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mark M. Sasaki
- Molecular Diagnostics of Abbott, Des Plaines, Illinois, USA
| | - April Kegl
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tanjina Akter
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tanisha Dickerson
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Momka Narlieva
- Department of Pathology, Montefiore Medical Center, Bronx, New York, USA
| | - Nhi Nhan
- Department of Pathology, Montefiore Medical Center, Bronx, New York, USA
| | - Tianxi Liu
- Department of Pathology, Montefiore Medical Center, Bronx, New York, USA
| | - Patricia Jim
- TriCore Reference Laboratories, Albuquerque, New Mexico, USA
| | - Stephen Young
- TriCore Reference Laboratories, Albuquerque, New Mexico, USA
| | - Erika Orner
- Department of Pathology, Montefiore Medical Center, Bronx, New York, USA
| | - Phyu Thwe
- Department of Pathology, Montefiore Medical Center, Bronx, New York, USA
| | - Danijela Lucic
- Molecular Diagnostics of Abbott, Des Plaines, Illinois, USA
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Puliyanda DP, Jordan SC. Management of the sensitized pediatric renal transplant candidate. Pediatr Transplant 2024; 28:e14694. [PMID: 38400645 DOI: 10.1111/petr.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/14/2023] [Accepted: 01/05/2024] [Indexed: 02/25/2024]
Abstract
Kidney transplantation is the treatment of choice for patients with ESRD as it is associated with improved patient survival and better quality of life, especially in children. There are several barriers to a successful transplant including organ shortage, anatomic barriers, and immunologic barriers. One of the biggest immunologic barriers that precludes transplantation is sensitization, when patients have antibodies prior to transplantation, resulting in positive crossmatches with donor. 30%-40% of adult patients on the wait list are sensitized. There is a growing number of pediatric patients on the wait list who are sensitized. This poses a unique challenge to the pediatric transplant community. Therefore, attempts to perform desensitization to remove or suppress pathogenic HLA antibodies resulting in acceptable crossmatches, and ultimately a successful transplant, while reducing the risk of acute rejection, are much needed in these children. This review article aims to address the management of such patients both prior to transplantation, with strategies to overcome sensitization, and after transplantation with monitoring for allograft rejection and other complications.
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Affiliation(s)
- Dechu P Puliyanda
- Department of Pediatrics, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Stanley C Jordan
- Department of Pediatrics, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
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7
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Graver AS, Lee D, Power DA, Whitlam JB. Understanding Donor-derived Cell-free DNA in Kidney Transplantation: An Overview and Case-based Guide for Clinicians. Transplantation 2023; 107:1675-1686. [PMID: 36579675 DOI: 10.1097/tp.0000000000004482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Kidney transplant recipients undergo lifelong monitoring of allograft function and evaluation for transplant complications. The current monitoring paradigm utilizes blood, urine, and tissue markers that are insensitive, nonspecific, or invasive to obtain. As a result, problems are detected late, after significant damage has accrued, and often beyond the time at which complete resolution is possible. Indeed, most kidney transplants eventually fail, usually because of chronic rejection and other undetected injury. There is a clear need for a transplant-specific biomarker that enables a proactive approach to monitoring via early detection of reversible pathology. A biomarker that supports timely and personalized treatment would assist in achieving the ultimate goal of improving allograft survival and limiting therapeutic toxicity to the recipient. Donor-derived cell-free DNA (ddcfDNA) has been proposed as one such transplant biomarker. Although the test is presently utilized most in the United States, it is conceivable that its use will become more widespread. This review covers aspects of ddcfDNA that support informed use of the test by general nephrologists, including the basic biology of ddcfDNA, methodological nuances of testing, and general recommendations for use in the kidney transplant population. Clinical contexts are used to illustrate evidence-supported interpretation of ddcfDNA results and subsequent management. Finally, knowledge gaps and areas for further study are discussed.
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Affiliation(s)
- Alison S Graver
- Kidney Transplant Service, Department of Nephrology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Darren Lee
- Kidney Transplant Service, Department of Nephrology, Austin Health, Heidelberg, VIC, Australia
- Department of Renal Medicine, Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - David A Power
- Kidney Transplant Service, Department of Nephrology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - John B Whitlam
- Kidney Transplant Service, Department of Nephrology, Austin Health, Heidelberg, VIC, Australia
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia
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Jiménez-Coll V, El Kaaoui El Band J, Llorente S, González-López R, Fernández-González M, Martínez-Banaclocha H, Galián JA, Botella C, Moya-Quiles MR, Minguela A, Legaz I, Muro M. All That Glitters in cfDNA Analysis Is Not Gold or Its Utility Is Completely Established Due to Graft Damage: A Critical Review in the Field of Transplantation. Diagnostics (Basel) 2023; 13:1982. [PMID: 37370877 DOI: 10.3390/diagnostics13121982] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/24/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
In kidney transplantation, a biopsy is currently the gold standard for monitoring the transplanted organ. However, this is far from an ideal screening method given its invasive nature and the discomfort it can cause the patient. Large-scale studies in renal transplantation show that approximately 1% of biopsies generate major complications, with a risk of macroscopic hematuria greater than 3.5%. It would not be until 2011 that a method to detect donor-derived cell-free DNA (dd-cfDNA) employing digital PCR was devised based on analyzing the differences in SNPs between the donor and recipient. In addition, since the initial validation studies were carried out at the specific moments in which rejection was suspected, there is still not a good understanding of how dd-cfDNA levels naturally evolve post-transplant. In addition, various factors, both in the recipient and the donor, can influence dd-cfDNA levels and cause increases in the levels of dd-cfDNA themselves without suspicion of rejection. All that glitters in this technology is not gold; therefore, in this article, we discuss the current state of clinical studies, the benefits, and disadvantages.
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Affiliation(s)
- Victor Jiménez-Coll
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Jaouad El Kaaoui El Band
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Santiago Llorente
- Nephrology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Rosana González-López
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Marina Fernández-González
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Helios Martínez-Banaclocha
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - José Antonio Galián
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Carmen Botella
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - María Rosa Moya-Quiles
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Alfredo Minguela
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Isabel Legaz
- Department of Legal and Forensic Medicine, Biomedical Research Institute of Murcia (IMIB), Faculty of Medicine, Regional Campus of International Excellence "Campus Mare Nostrum", University of Murcia, 30100 Murcia, Spain
| | - Manuel Muro
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
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Yoo A, Riedel A, Qian I, Bartosic A, Soltani R, Kibria G, Haririan A, Drachenberg CB, Abrams PL, Odorico JS, Cooper M, Bromberg JS, Scalea JR. An Initial Analysis of the Baseline Levels of Dd-cfDNA After Pancreas Transplantation: A Prospective Study From High-volume Centers in the United States. Transplant Direct 2023; 9:e1459. [PMID: 36935870 PMCID: PMC10019258 DOI: 10.1097/txd.0000000000001459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 03/17/2023] Open
Abstract
Pancreas transplantation offers patients with diabetes an opportunity for glucose homeostasis. Current blood tests to surveil for rejection have poor sensitivity and specificity for identifying rejection, and pancreas biopsies are challenging and associated with morbidity and graft loss. Donor-derived cell-free DNA (dd-cfDNA) is shed from transplanted organs and detectable in peripheral blood. Thus, a potential dd-cfDNA blood test assessing rejection would be clinically advantageous. Methods One hundred eighty-one dd-cfDNA samples (n) were collected from 77 patients (N) up to 132 mo posttransplant. Results The median dd-cfDNA level among all subjects was 0.28% (0.13%, 0.71%). In simultaneous pancreas-kidney (SPK) transplant recipients, the median dd-cfDNA level was 0.29% (0.13%, 0.71%), and it was 0.23% (0.08%, 0.71%) in pancreas transplant alone (PTA) recipients. When isolating for when without infection or rejection, the median dd-cfDNA level was 0.28% (0.13%, 0.64%) for SPK and 0.20% (0.00%, 0.32%) for PTA. Both transplant types approached 1.0% ≤1 mo posttransplant followed by a decrease in median dd-cfDNA. During episodes of rejection or infection, median dd-cfDNA levels were greater among all transplant types. Conclusions The mean dd-cfDNA level for all pancreas transplant recipients is <1.0%, consistent with the published kidney transplant rejection threshold (>1.0%), regardless of SPK or PTA. Early posttransplant dd-cfDNA levels are transiently higher than later measurements. Dd-cfDNA elevation also correlates with rejection and infection and thus is a promising biomarker for surveilling pancreas transplant dysfunction.
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Affiliation(s)
- Ashley Yoo
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Alexandria Riedel
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ian Qian
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Amanda Bartosic
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Rudi Soltani
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Gulam Kibria
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Abdolreza Haririan
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Cinthia B. Drachenberg
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - Jon S. Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Jonathan S. Bromberg
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Joseph R. Scalea
- Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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10
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Jimenez-Coll V, Llorente S, Boix F, Alfaro R, Galián JA, Martinez-Banaclocha H, Botella C, Moya-Quiles MR, Muro-Pérez M, Minguela A, Legaz I, Muro M. Monitoring of Serological, Cellular and Genomic Biomarkers in Transplantation, Computational Prediction Models and Role of Cell-Free DNA in Transplant Outcome. Int J Mol Sci 2023; 24:ijms24043908. [PMID: 36835314 PMCID: PMC9963702 DOI: 10.3390/ijms24043908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023] Open
Abstract
The process and evolution of an organ transplant procedure has evolved in terms of the prevention of immunological rejection with the improvement in the determination of immune response genes. These techniques include considering more important genes, more polymorphism detection, more refinement of the response motifs, as well as the analysis of epitopes and eplets, its capacity to fix complement, the PIRCHE algorithm and post-transplant monitoring with promising new biomarkers that surpass the classic serum markers such as creatine and other similar parameters of renal function. Among these new biomarkers, we analyze new serological, urine, cellular, genomic and transcriptomic biomarkers and computational prediction, with particular attention to the analysis of donor free circulating DNA as an optimal marker of kidney damage.
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Affiliation(s)
- Víctor Jimenez-Coll
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
| | - Santiago Llorente
- Nephrology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
| | - Francisco Boix
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
| | - Rafael Alfaro
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
| | - José Antonio Galián
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
| | - Helios Martinez-Banaclocha
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
| | - Carmen Botella
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
| | - María R. Moya-Quiles
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
| | - Manuel Muro-Pérez
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
| | - Alfredo Minguela
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
| | - Isabel Legaz
- Department of Legal and Forensic Medicine, Biomedical Research Institute (IMIB), Regional Campus of International Excellence “Campus Mare Nostrum”, Faculty of Medicine, University of Murcia, 30100 Murcia, Spain
- Correspondence: (I.L.); (M.M.); Tel.: +34-699986674 (M.M.); Fax: +34-868834307 (M.M.)
| | - Manuel Muro
- Immunology Service, Instituto Murciano de Investigación Biosanitaria (IMIB), Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA), 30120 Murcia, Spain
- Correspondence: (I.L.); (M.M.); Tel.: +34-699986674 (M.M.); Fax: +34-868834307 (M.M.)
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11
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Anti-interleukin-6 Antibody Clazakizumab in Antibody-mediated Kidney Transplant Rejection: Effect on Donor-derived Cell-free DNA and C-X-C Motif Chemokine Ligand 10. Transplant Direct 2022; 8:e1406. [PMID: 36382130 PMCID: PMC9649278 DOI: 10.1097/txd.0000000000001406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/18/2022] [Indexed: 11/29/2022] Open
Abstract
UNLABELLED Targeting interleukin-6 (IL-6) was shown to counteract donor-specific antibody production and antibody-mediated rejection (AMR) activity. It is not known whether, or to what extent, IL-6 antagonism modulates biomarkers indicative of tissue damage (donor-derived cell-free DNA [dd-cfDNA]) and parenchymal inflammation (C-X-C motif chemokine ligand [CXCL] 10). METHODS We report a secondary endpoint analysis of a phase 2 trial of anti-IL-6 antibody clazakizumab in late AMR (ClinicalTrials.gov, NCT03444103). Twenty kidney transplant recipients were randomized to treatment with clazakizumab or placebo over 12 wk (part A), followed by an extension in which all recipients received clazakizumab through week 52 (part B). Biomarkers were evaluated at day 0 and after 12 and 52 wk, respectively. RESULTS Fractional dd-cfDNA (dd-cfDNA[%]) did not significantly change under clazakizumab, with no differences between study arms (clazakizumab versus placebo) at week 12 (1.65% [median; interquartile range: 0.91%-2.78%] versus 0.97% [0.56%-2.30%]; P = 0.25) and no significant decrease from weeks 12 to 52 (1.15% [0.70%-2.38%] versus 1.0% [0.61%-1.70%]; P = 0.25). Similarly, urine CXCL10 was not different between groups at week 12 (55.7 [41.0-91.4] versus 60.2 [48.8-208.7.0] pg/mg creatinine; P = 0.44) and did not change over part B (CXCL10 [pg/mg creatinine]: from 58 [46.3-93.1] to 67.4 [41.5-132.0] pg/mL creatinine; P = 0.95). Similar results were obtained for serum CXCL10. There was no association between biomarker levels and resolution of molecular and morphologic AMR activity. CONCLUSIONS Our results suggest that IL-6 blockade does not significantly affect levels of dd-cfDNA[%] and CXCL10. Subtle responses to this therapeutic principle may be overlooked by early biomarker surveillance.
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12
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Mayer KA, Omic H, Weseslindtner L, Doberer K, Reindl-Schwaighofer R, Viard T, Tillgren A, Haindl S, Casas S, Eskandary F, Heinzel A, Kozakowski N, Kikić Ž, Böhmig GA, Eder M. Levels of donor-derived cell-free DNA and chemokines in BK polyomavirus-associated nephropathy. Clin Transplant 2022; 36:e14785. [PMID: 35894263 PMCID: PMC10078585 DOI: 10.1111/ctr.14785] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND BK polyomavirus-associated nephropathy (BKPyVAN) carries a risk of irreversible allograft injury. While detection of BK viremia and biopsy assessment are the current diagnostic gold standard, the diagnostic value of biomarkers reflecting tissue injury (donor-derived cell-free DNA [dd-cfDNA]) or immune activation (C-X-C motif chemokine ligand [CXCL]9 and CXCL10) remains poorly defined. METHODS For this retrospective study, 19 cases of BKPyVAN were selected from the Vienna transplant cohort (biopsies performed between 2012 and 2019). Eight patients with T cell-mediated rejection (TCMR), 17 with antibody-mediated rejection (ABMR) and 10 patients without polyomavirus nephropathy or rejection served as controls. Fractions of dd-cfDNA were quantified using next-generation sequencing and CXCL9 and CXCL10 were detected using multiplex immunoassays. RESULTS BKPyVAN was associated with a slight increase in dd-cfDNA (median; interquartile range: .38% [.27%-1.2%] vs. .21% [.12%-.34%] in non-rejecting control patients; p = .005). Levels were far lower than in ABMR (1.2% [.82%-2.5%]; p = .004]), but not different from TCMR (.54% [.26%-3.56%]; p = .52). Within the BKPyVAN cohort, we found no relationship between dd-cfDNA levels and the extent of tubulo-interstitial infiltrates, BKPyVAN class and BK viremia/viruria, respectively. In some contrast to dd-cfDNA, concentrations of urinary CXCL9 and CXCL10 exceeded those detected in ABMR, but similar increases were also found in TCMR. CONCLUSION BKPyVAN can induce moderate increases in dd-cfDNA and concomitant high urinary excretion of chemokines, but this pattern may be indistinguishable from that of TCMR. Our results argue against a significant value of these biomarkers to reliably distinguish BKPyVAN from rejection.
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Affiliation(s)
- Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Haris Omic
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Roman Reindl-Schwaighofer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thierry Viard
- CareDx Inc., Brisbane, San Francisco, California, USA
| | | | - Susanne Haindl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Silvia Casas
- CareDx Inc., Brisbane, San Francisco, California, USA
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andreas Heinzel
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Željko Kikić
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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13
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Dandamudi R, Gu H, Goss CW, Walther L, Dharnidharka VR. Longitudinal Evaluation of Donor-Derived Cellfree DNA in Pediatric Kidney Transplantation. Clin J Am Soc Nephrol 2022; 17:1646-1655. [PMID: 36302566 PMCID: PMC9718036 DOI: 10.2215/cjn.03840322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 09/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Donor-derived cellfree DNA (cfDNA) is a less-invasive marker of allograft injury compared with kidney biopsy. However, donor-derived cfDNA has not yet been extensively tested in children, where the test may have different characteristics. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We assayed donor-derived cfDNA (AlloSure; CareDx) from 290 stored plasma samples from a prospective biobank at our center, collected from 57 children monthly in the first year postkidney transplant between January 2013 and December 2019. We assessed the kinetic changes in donor-derived cfDNA levels within the first year post-transplant. We analyzed donor-derived cfDNA levels for associations with biopsy-proven acute rejection using area under the receiver operating characteristic curve to longitudinal plasma and urine BK viral loads using linear mixed models. We analyzed the prognostic effect of an elevated donor-derived cfDNA level on the eGFR 30 days after the assay via Kolmogorov-Smirnov two-sample tests or on measured GFR or interstitial fibrosis at 12 months post-transplant. RESULTS The donor-derived cfDNA levels in children remained persistently elevated for at least 4 months post-transplant, more so if there is greater disparity in size between the donor and the recipient, before reaching a steady low level. A donor-derived cfDNA level of >1% discriminated between biopsy-proven acute rejection with a receiver operating characteristic area under the curve of 0.82 (95% confidence interval, 0.71 to 0.93). During BK viruria or viremia, patients had a significantly higher median donor-derived cfDNA than before or after and a significant rise within the same patient. A donor-derived cfDNA of >0.5% predicted a wider spread in the eGFR over the next 30 days but not the 12-month outcomes. CONCLUSIONS In children, donor-derived cfDNA is a valuable, less invasive biomarker for assessment of allograft rejection and injury. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_10_27_CJN03840322.mp3.
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Affiliation(s)
- Raja Dandamudi
- Division of Pediatric Nephrology, Hypertension and Pheresis, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Hongjie Gu
- Division of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Charles W. Goss
- Division of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Leslie Walther
- Division of Pediatric Nephrology, Hypertension and Pheresis, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Vikas R. Dharnidharka
- Division of Pediatric Nephrology, Hypertension and Pheresis, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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14
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The Current State of Donor-Derived Cell-Free DNA Use in Allograft Monitoring in Kidney Transplantation. J Pers Med 2022; 12:jpm12101700. [PMID: 36294839 PMCID: PMC9605518 DOI: 10.3390/jpm12101700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/21/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Renal transplantation is the definitive therapy for patients suffering from end-stage renal disease. Though there have been significant advances in immunosuppression in these patients, there is still up to 30% acute and subclinical rejection. Current standards employ lab markers of renal function and biopsy results for accurate diagnosis. However, donor derived cell-free DNA has been identified as a measurable lab test that may be able to adequately diagnose rejection at early stages, precluding the need for invasive procedures like biopsy. We obtained published data directly from companies that offer ddcfDNA assay tests and additionally conducted a literature review using databases like PUBMED and NIH U.S. National Library of Medicine. We comprehensively compare the most used ddcfDNA assays, delineate their respective limitations, and further explore future directions in the utility of ddcfDNA in renal transplant patients.
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15
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Wen J, Sun R, Yang H, Ran Q, Hou Y. Detection of BK polyomavirus-associated nephropathy using plasma graft-derived cell-free DNA: Development of a novel algorithm from programmed monitoring. Front Immunol 2022; 13:1006970. [PMID: 36275762 PMCID: PMC9582120 DOI: 10.3389/fimmu.2022.1006970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Graft-derived cell-free DNA (GcfDNA) is a promising non-invasive biomarker for detecting allograft injury. In this study, we aimed to evaluate the efficacy of programmed monitoring of GcfDNA for identifying BK polyomavirus-associated nephropathy (BKPyVAN) in kidney transplant recipients. We recruited 158 kidney transplant recipients between November 2020 and December 2021. Plasma GcfDNA was collected on the tenth day, first month, third month, and sixth month for programmed monitoring and one day before biopsy. ΔGcfDNA (cp/mL) was obtained by subtracting the baseline GcfDNA (cp/mL) from GcfDNA (cp/mL) of the latest programmed monitoring before biopsy. The receiver operating characteristic curve showed the diagnostic performance of GcfDNA (cp/mL) at biopsy time and an optimal area under the curve (AUC) of 0.68 in distinguishing pathologically proven BKPyVAN from pathologically unconfirmed BKPyVAN. In contrast, ΔGcfDNA (cp/mL) had a sensitivity and specificity of 80% and 84.6%, respectively, and an AUC of 0.83. When distinguishing clinically diagnosed BKPyVAN from clinical excluded BKPyVAN, the AUC of GcfDNA (cp/mL) was 0.59 at biopsy time, and ΔGcfDNA (cp/mL) had a sensitivity and specificity of 81.0% and 76.5%, respectively, and an AUC of 0.81. Plasma ΔGcfDNA (cp/mL) was not significantly different between TCMR [0.15 (0.08, 0.24) cp/mL] and pathologically proven BKPyVAN[0.34 (0.20, 0.49) cp/mL]. In conclusion, we recommend programmed monitoring of plasma GcfDNA levels after a kidney transplant. Based on our findings from the programmed monitoring, we have developed a novel algorithm that shows promising results in identifying and predicting BKPyVAN.
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Affiliation(s)
- Jingyu Wen
- Department of Medical Insurance, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Rongcun Sun
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Organ Transplantation, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Hongji Yang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Organ Transplantation, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province & Organ Transplantation Center, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| | - Qing Ran
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Organ Transplantation, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province & Organ Transplantation Center, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| | - Yifu Hou
- Department of Organ Transplantation, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Clinical Immunology Translational Medicine Key Laboratory of Sichuan Province & Organ Transplantation Center, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
- *Correspondence: Yifu Hou,
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16
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BK Virus Nephropathy in Kidney Transplantation: A State-of-the-Art Review. Viruses 2022; 14:v14081616. [PMID: 35893681 PMCID: PMC9330039 DOI: 10.3390/v14081616] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/10/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Abstract
BK virus maintains a latent infection that is ubiquitous in humans. It has a propensity for reactivation in the setting of a dysfunctional cellular immune response and is frequently encountered in kidney transplant recipients. Screening for the virus has been effective in preventing progression to nephropathy and graft loss. However, it can be a diagnostic and therapeutic challenge. In this in-depth state-of-the-art review, we will discuss the history of the virus, virology, epidemiology, cellular response, pathogenesis, methods of screening and diagnosis, evidence-based treatment strategies, and upcoming therapeutics, along with the issue of re-transplantation in patients.
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17
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Kant S, Brennan DC. Donor Derived Cell Free DNA in Kidney Transplantation: The Circa 2020–2021 Update. Transpl Int 2022; 35:10448. [PMID: 35721467 PMCID: PMC9198901 DOI: 10.3389/ti.2022.10448] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/29/2022] [Indexed: 12/11/2022]
Abstract
The routine surveillance of kidney transplant allografts has relied on imperfect non-invasive biomarkers such as creatinine and urinary indices, while the gold standard allograft biopsy is associated with risk of bleeding, organ injury and sampling errors. Donor derived cell free DNA (dd-cfDNA) is being employed as a biomarker that addresses limitations of these surveillance methods, albeit has inherent drawbacks. This review provides an update on the enhanced understanding of dd-cfDNA and its expanded use beyond the conventional indication of detecting allograft rejection.
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Affiliation(s)
- Sam Kant
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Comprehensive Transplant Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Sam Kant,
| | - Daniel C. Brennan
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Comprehensive Transplant Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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18
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Chen XT, Qiu J, Wu ZX, Zhang H, Chen T, Yang SC, Zhao GD, He Y, Shen X, Luo JQ, Huang Y, Wang CX, Chen LZ, Wu CL, Huang G. OUP accepted manuscript. Clin Chem 2022; 68:814-825. [PMID: 35587713 DOI: 10.1093/clinchem/hvac053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/08/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Xu-Tao Chen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Jiang Qiu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Zi-Xuan Wu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Hui Zhang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Tong Chen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Shi-Cong Yang
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Guo-Dong Zhao
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Yu He
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Xue Shen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Jin-Quan Luo
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Yang Huang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Chang-Xi Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Li-Zhong Chen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Cheng-Lin Wu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
| | - Gang Huang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Rd. 2, Guangzhou, Guangdong Province, China, 510080
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19
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Bu L, Gupta G, Pai A, Anand S, Stites E, Moinuddin I, Bowers V, Jain P, Axelrod DA, Weir MR, Wolf-Doty TK, Zeng J, Tian W, Qu K, Woodward R, Dholakia S, De Golovine A, Bromberg JS, Murad H, Alhamad T. Validation and clinical outcome in assessing donor-derived cell-free DNA monitoring insights of kidney allografts with longitudinal surveillance (ADMIRAL) study. Kidney Int 2021; 101:793-803. [PMID: 34953773 DOI: 10.1016/j.kint.2021.11.034] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/04/2021] [Accepted: 11/22/2021] [Indexed: 12/18/2022]
Abstract
The use of routine monitoring of donor-derived cell-free DNA (dd-cfDNA) after kidney transplant may allow clinicians to identify subclinical allograft injury and intervene prior to development of clinically evident graft injury. To evaluate this, data from 1092 kidney transplant recipients monitored for dd-cfDNA over a three year period was analyzed to assess the association of dd-cfDNA with histologic evidence of allograft rejection. Elevation of dd-cfDNA (0.5% or more) was significantly correlated with clinical and subclinical allograft rejection. dd-cfDNA values of 0.5% or more were associated with a nearly three-fold increase in risk development of de novo donor specific antibodies (hazard ratio 2.71) and were determined to be elevated a median of 91 days (inter quartile range of 30-125 days) ahead of donor specific antibody identification. Persistently elevated dd-cfDNA (more than one result above the 0.5% threshold) predicted over a 25% decline in the estimated glomerular filtration rate over three years (hazard ratio 1.97). Therefore, routine monitoring of dd-cfDNA allowed early identification of clinically important graft injury. Biomarker monitoring complemented histology and traditional laboratory surveillance strategies as a prognostic marker and risk-stratification tool post-transplant. Thus, persistently low dd-cfDNA levels may accurately identify allograft quiescence, or absence of injury, paving the way for personalization of immunosuppression trials.
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Affiliation(s)
| | | | - Akshta Pai
- University of Texas Health Science Center, Memorial Hermann Hospital
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20
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Chopra B, Sureshkumar KK. Emerging role of cell-free DNA in kidney transplantation. World J Exp Med 2021; 11:55-65. [PMID: 34877265 PMCID: PMC8611196 DOI: 10.5493/wjem.v11.i5.55] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/01/2021] [Accepted: 09/01/2021] [Indexed: 02/06/2023] Open
Abstract
Monitoring kidney transplants for rejection conventionally includes serum creatinine, immunosuppressive drug levels, proteinuria, and donor-specific antibody (DSA). Serum creatinine is a late marker of allograft injury, and the predictive ability of DSA regarding risk of rejection is variable. Histological analysis of an allograft biopsy is the standard method for diagnosing rejection but is invasive, inconvenient, and carries risk of complications. There has been a long quest to find a perfect biomarker that noninvasively predicts tissue injury caused by rejection at an early stage, so that diagnosis and treatment could be pursued without delay in order to minimize irreversible damage to the allograft. In this review, we discuss relatively novel research on identifying biomarkers of tissue injury, specifically elaborating on donor-derived cell-free DNA, and its clinical utility.
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Affiliation(s)
- Bhavna Chopra
- Nephrology and Hypertension, Allegheny General Hospital, Pittsburgh, PA 15212, United States
| | - Kalathil K Sureshkumar
- Division of Nephrology, Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United State
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21
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Shen J, Guo L, Lei W, Liu S, Yan P, Liu H, Zhou J, Zhou Q, Liu F, Jiang T, Wang H, Wu J, Chen J, Wang R. Urinary donor-derived cell-free DNA as a non-invasive biomarker for BK polyomavirus-associated nephropathy. J Zhejiang Univ Sci B 2021; 22:917-928. [PMID: 34783222 DOI: 10.1631/jzus.b2100131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BK polyomavirus-associated nephropathy (BKPyVAN) is a common cause of allograft failure. However, differentiation between BKPyVAN and type I T cell-mediated rejection (TCMR) is challenging when simian virus 40 (SV40) staining is negative, because of the similarities in histopathology. This study investigated whether donor-derived cell-free DNA (ddcfDNA) can be used to differentiate BKPyVAN. Target region capture sequencing was applied to detect the ddcfDNAs of 12 recipients with stable graft function, 22 with type I TCMR, 21 with proven BKPyVAN, and 5 with possible PyVAN. We found that urinary ddcfDNA levels were upregulated in recipients with graft injury, whereas plasma ddcfDNA levels were comparable for all groups. The median urinary concentrations and fractions of ddcfDNA in proven BKPyVAN recipients were significantly higher than those in type I TCMR recipients (10.4 vs. 6.1 ng/mL, P<0.001 and 68.4% vs. 55.3%, P=0.013, respectively). Urinary ddcfDNA fractions (not concentrations) were higher in the BKPyVAN-pure subgroup than in the BKPyVAN-rejection-like subgroup (81.30% vs. 56.64%, P=0.025). With a cut-off value of 7.81 ng/mL, urinary ddcfDNA concentrations distinguished proven BKPyVAN from type I TCMR (area under the curve (AUC)=0.848, 95% confidence interval (95% CI): 0.734 to 0.963). These findings suggest that urinary ddcfDNA is a non-invasive biomarker which can reliably differentiate BKPyVAN from type I TCMR.
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Affiliation(s)
- Jia Shen
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Luying Guo
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Wenhua Lei
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Shuaihui Liu
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Pengpeng Yan
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Haitao Liu
- AlloDx (Shanghai) Biotech., Co., Ltd., Shanghai 201100, China
| | - Jingyi Zhou
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Qin Zhou
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Feng Liu
- AlloDx (Shanghai) Biotech., Co., Ltd., Shanghai 201100, China
| | - Tingya Jiang
- AlloDx (Shanghai) Biotech., Co., Ltd., Shanghai 201100, China
| | - Huiping Wang
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Jianyong Wu
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Rending Wang
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China. .,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China. .,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China. .,Zhejiang University Institute of Nephrology, Hangzhou 310003, China. .,Organ Donation and Coordination Office, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.
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22
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Qazi Y, Patel A, Fajardo M, McCormick S, Fehringer G, Ahmed E, Malhotra M, Demko ZP, Billings PR, Tabriziani H, Gauthier P. Incorporation of Donor-derived Cell-free DNA Into Clinical Practice for Renal Allograft Management. Transplant Proc 2021; 53:2866-2872. [PMID: 34774309 DOI: 10.1016/j.transproceed.2021.09.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Donor-derived cell-free DNA (dd-cfDNA) in plasma is an established noninvasive biomarker for allograft injury and rejection. A single-nucleotide polymorphism (SNP)-based massively multiplexed polymerase chain reaction methodology can be used to quantify dd-cfDNA in kidney transplant recipients. In this study we describe our clinical experience in using a SNP-based dd-cfDNA assay for the management of active rejection in renal transplant recipients. METHODS To assess the clinical utility of a clinically available SNP-based massively multiplexed polymerase chain reaction dd-cfDNA assay, we analyzed biopsy data contemporaneous to dd-cfDNA results at 33 participating clinics and calculated the rate of rejection in dd-cfDNA-matched biopsy results. RESULTS A total of 1347 dd-cfDNA test samples from 879 patients were accessioned from October 3, 2019, to November 2, 2020. The dd-cfDNA testing classified 25.2% (340/1347) of samples as high-risk (dd-cfDNA fraction ≥ 1%). Clinical follow-up was available for 32.1% (109/340) of the high-risk results, which included samples from 28 patients with definitive biopsy results within 2 weeks of dd-cfDNA testing. Pathology reports indicated a 64% (18/28) rate of active rejection in biopsy result-matched samples. Total cfDNA measurements indicated a skewed distribution and a correlation with dd-cfDNA-derived patient risk classification. CONCLUSIONS This is the first report showing the impact of dd-cfDNA on patient management in a multicenter real-world clinical cohort. The data indicate that incorporating dd-cfDNA testing into practice may improve physician decision making regarding renal allograft recipients.
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Affiliation(s)
- Yasir Qazi
- Department of Medicine, University of Southern California, Los Angeles, California
| | - Anup Patel
- Saint Barnabas Medical Center, Livingston, New Jersey
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23
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Mayer KA, Doberer K, Tillgren A, Viard T, Haindl S, Krivanec S, Reindl-Schwaighofer R, Eder M, Eskandary F, Casas S, Wahrmann M, Regele H, Böhmig GA. Diagnostic value of donor-derived cell-free DNA to predict antibody-mediated rejection in donor-specific antibody-positive renal allograft recipients. Transpl Int 2021; 34:1689-1702. [PMID: 34448270 PMCID: PMC8456909 DOI: 10.1111/tri.13970] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/30/2021] [Accepted: 07/05/2021] [Indexed: 11/28/2022]
Abstract
Circulating donor‐specific antibodies (DSA) do not necessarily indicate antibody‐mediated rejection (ABMR). Here, we evaluated the diagnostic value of donor‐derived cell‐free DNA (dd‐cfDNA) as an add‐on to DSA detection. The study included two independent cohorts of DSA+ kidney allograft recipients, 45 subclinical cases identified by cross‐sectional antibody screening (cohort 1), and 30 recipients subjected to indication biopsies (cohort 2). About 50% of the DSA+ recipients had ABMR and displayed higher dd‐cfDNA levels than DSA+ABMR− recipients (cohort 1: 1.90% [median; IQR: 0.78–3.90%] vs. 0.52% [0.35–0.72%]; P < 0.001); (cohort 2: 1.20% [0.82–2.50%] vs. 0.59% [0.28–2.05%]; P = 0.086). Receiver operating characteristic (ROC) analysis revealed an area under the curve (AUC) of 0.89 and 0.69 for dd‐cfDNA, and 0.88 and 0.77 for DSA mean fluorescence intensity (MFI), respectively. In combined models, adding dd‐cfDNA to DSA‐MFI or vice versa significantly improved the diagnostic accuracy. Limited diagnostic performance of dd‐cfDNA in cohort 2 was related to the frequent finding of other types of graft injury among ABMR− recipients, like T cell‐mediated rejection or glomerulonephritis. For dd‐cfDNA in relation to injury of any cause an AUC of 0.97 was calculated. Monitoring of dd‐cfDNA in DSA+ patients may be a useful tool to detect ABMR and other types of injury.
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Affiliation(s)
- Katharina A Mayer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Konstantin Doberer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | | | - Susanne Haindl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Sebastian Krivanec
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Roman Reindl-Schwaighofer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Silvia Casas
- CareDx Inc., Brisbane, South San Francisco, CA, USA
| | - Markus Wahrmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Heinz Regele
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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24
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Donor-derived Cell-free DNA in Solid-organ Transplant Diagnostics: Indications, Limitations, and Future Directions. Transplantation 2021; 105:1203-1211. [PMID: 33534526 DOI: 10.1097/tp.0000000000003651] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The last few years have seen an explosion in clinical research focusing on the use of donor-derived cell-free DNA (dd-cfDNA) in solid-organ transplants (SOT). Although most of the literature published so far focuses on kidney transplants, there are several recent as well as ongoing research studies on heart, lung, pancreas, and liver transplants. Though initially studied as a noninvasive means of identifying subclinical or acute rejection in SOT, it is rapidly becoming clear that instead of being a specific marker for allograft rejection, dd-cfDNA is more appropriately described as a marker of severe injury, although the most common cause of this injury is allograft rejection. Multiple studies in kidney transplants have shown that although sensitivity for the diagnosis of antibody-mediated rejection is excellent, it is less so for T-cell-mediated rejection. It is possible that combining dd-cfDNA with other novel urine- or blood-based biomarkers may increase the sensitivity for the diagnosis of rejection. Irrespective of the cause, though, elevated dd-cfDNA seems to portend adverse allograft prognosis and formation of de novo donor-specific antibody. Although current data do not lend themselves to a clear conclusion, ongoing studies may reveal the utility of serial surveillance for the management of SOT as following levels of dd-cfDNA over time may provide windows of opportunity to intervene early and before irreversible allograft injury. Finally, cost-effectiveness studies will be needed to guide the ideal incorporation of dd-cfDNA into routine clinical practice.
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25
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Donor-derived Cell-free DNA Kinetics Post-kidney Transplant Biopsy. Transplant Direct 2021; 7:e703. [PMID: 34056078 PMCID: PMC8154469 DOI: 10.1097/txd.0000000000001149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 11/26/2022] Open
Abstract
Background. Donor-derived cell-free DNA (dd-cfDNA) has generated interest as a biomarker for kidney injury including transplant (KT) rejection. It is possible that the KT biopsy procedure can cause the release of dd-cfDNA, therefore affecting the reliability of this assay in the postbiopsy period. We evaluated the effect of KT biopsy on the kinetics of dd-cfDNA. Methods. We conducted a single-arm prospective study. Samples were collected from 16 adult KT recipients undergoing KT biopsy. All participants had samples drawn within 8 h before the biopsy (prebiopsy), within 20 min (hour 0), 2 h (hour 2), and 24–48 h (hours 24–48) after the biopsy. We evaluated the change in dd-cfDNA from the prebiopsy time point to the following 3 time points after the biopsy. Results. At hour 0 and hour 2, there was a significantly larger log dd-cfDNA mean score compared with the prebiopsy score (least square mean estimate 0.4 [0.17-0.63] and 0.39 [0.09-0.68], respectively). By 24–28 h postbiopsy, there was no significant difference in log dd-cfDNA mean score compared with the prebiopsy score (least square mean estimate −0.21 [−0.6 to 0.19]). Conclusions. Mechanical injury from a KT biopsy can transiently increase circulating dd-cfDNA. The increase resolves by 24–48 h after the biopsy. Providers should wait 48 h postbiopsy to obtain dd-cfDNA levels to establish the correct baseline to be used for monitoring.
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26
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Kant S, Brennan DC. Donor-Derived Cell-Free DNA in Kidney Transplantation: Origins, Present and a Look to the Future. ACTA ACUST UNITED AC 2021; 57:medicina57050482. [PMID: 34065914 PMCID: PMC8151129 DOI: 10.3390/medicina57050482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/05/2021] [Accepted: 05/09/2021] [Indexed: 11/16/2022]
Abstract
Since its first detection in 1948, donor-derived cell-free DNA (dd-cfDNA) has been employed for a myriad of indications in various medical specialties. It has had a far-reaching impact in solid organ transplantation, with the most widespread utilization in kidney transplantation for the surveillance and detection of allograft rejection. The purpose of this review is to track the arc of this revolutionary test—from origins to current use—along with examining challenges and future prospects though the lens of transplant nephrology.
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Affiliation(s)
- Sam Kant
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
- Comprehensive Transplant Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Correspondence:
| | - Daniel C. Brennan
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
- Comprehensive Transplant Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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27
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Kim MY, Brennan DC. Therapies for Chronic Allograft Rejection. Front Pharmacol 2021; 12:651222. [PMID: 33935762 PMCID: PMC8082459 DOI: 10.3389/fphar.2021.651222] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/10/2021] [Indexed: 12/14/2022] Open
Abstract
Remarkable advances have been made in the pathophysiology, diagnosis, and treatment of antibody-mediated rejection (ABMR) over the past decades, leading to improved graft outcomes. However, long-term failure is still high and effective treatment for chronic ABMR, an important cause of graft failure, has not yet been identified. Chronic ABMR has a relatively different phenotype from active ABMR and is a slowly progressive disease in which graft injury is mainly caused by de novo donor specific antibodies (DSA). Since most trials of current immunosuppressive therapies for rejection have focused on active ABMR, treatment strategies based on those data might be less effective in chronic ABMR. A better understanding of chronic ABMR may serve as a bridge in establishing treatment strategies to improve graft outcomes. In this in-depth review, we focus on the pathophysiology and characteristics of chronic ABMR along with the newly revised Banff criteria in 2017. In addition, in terms of chronic ABMR, we identify the reasons for the resistance of current immunosuppressive therapies and look at ongoing research that could play a role in setting better treatment strategies in the future. Finally, we review non-invasive biomarkers as tools to monitor for rejection.
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Affiliation(s)
| | - Daniel C. Brennan
- Department of Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
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28
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Dale BL, Bose S, Kuo S, Burns A, Daou P, Short J, Miles J. Transition of Renal Patients Using AlloSure Into Community Kidney Care (TRACK): Protocol for Long-Term Allograft Surveillance in Renal Transplant Recipients. JMIR Res Protoc 2021; 10:e25941. [PMID: 33720033 PMCID: PMC8088876 DOI: 10.2196/25941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with end-stage kidney disease require complex and expensive medical management. Kidney transplantation remains the treatment of choice for end-stage kidney disease and is considered superior to all other modalities of renal replacement therapy or dialysis. However, access to kidney transplant is limited by critical supply and demand, making it extremely important to ensure longevity of transplanted kidneys. This is prevented through lifelong immunosuppression, with caution not to overly suppress the immune system, resulting in toxicity and harm. Transition of care to community nephrologists after initial kidney transplantation and monitoring at a transplant center is an important process to ensure delivery of effective and patient-centric care closer to home. Once transplanted, laborious surveillance of the immune system and monitoring for potential rejection and injury are undertaken through an armamentarium of screening modalities. Posttransplant surveillance for kidney function and injury remains key to follow-up care. While kidney function, quantified by estimated glomerular filtration rate and serum creatinine, and kidney injury, measured by proteinuria and hematuria, are standard biomarkers used to monitor injury and rejection posttransplant, they have recently been demonstrated to be inferior in performance to that of AlloSure (CareDx Inc, Brisbane, CA) circulating donor-derived, cell-free DNA (dd-cfDNA). OBJECTIVE The outcomes and methods of monitoring renal transplant recipients posttransplant have remained stagnant over the past 15 years. The aim of this study is to consider intensive surveillance using AlloSure dd-cfDNA in an actively managed protocol, assessing whether it increases long-term allograft survival in kidney transplant recipients compared with current standard clinical care in community nephrology. METHODS The study protocol will acquire data from a phase IV observational trial to assess a cohort of renal transplant patients managed using AlloSure dd-cfDNA and patient care managers versus 1000 propensity-matched historic controls using United Network for Organ Sharing U.S. Scientific Registry of Transplant Recipients data. Data will be managed in a centralized electronic data server. The primary outcome will be superior allograft survival, as a composite of return to dialysis, retransplant, death due to allograft failure, and death with a functional graft (infection, malignancy, and cardiovascular death). The secondary endpoints will assess improved kidney function through decline in estimated glomerular filtration rate and immune activity through development of donor-specific antibodies. RESULTS The total sample is anticipated to be 3500 (2500 patients managed with AlloSure dd-cfDNA and 1000 propensity-matched controls). Active enrollment began in November 2020. CONCLUSIONS Based on a significant literature base, we believe implementing the surveillance of dd-cfDNA in the kidney transplant population will have a positive impact on graft survival. Through early identification of rejection and facilitating timely intervention, prolongation of allograft survival versus those not managed by dd-cfDNA surveillance protocol should be superior. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/25941.
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Affiliation(s)
| | - Subhasish Bose
- Lynchburg Nephrology Physicians, Charlottesville, VA, United States.,Division of Nephrology, Department of Medicine, University of Virginia Medical Center, Charlottesville, VA, United States
| | - Sheng Kuo
- Nephrology Associates PC, Queens, NY, United States
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