1
|
Bromberg JS, Bunnapradist S, Samaniego-Picota M, Anand S, Stites E, Gauthier P, Demko Z, Prewett A, Armer-Cabral M, Marshall K, Kaur N, Bloom MS, Tabriziani H, Bhorade S, Cooper M. Elevation of Donor-derived Cell-free DNA Before Biopsy-proven Rejection in Kidney Transplant. Transplantation 2024; 108:1994-2004. [PMID: 38595232 PMCID: PMC11335081 DOI: 10.1097/tp.0000000000005007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/02/2024] [Accepted: 02/11/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Standard-of-care biomarkers for renal allograft rejection are lagging indicators, signaling existing organ injury. This precludes early intervention, when immunological cascades leading to rejection are most susceptible. Donor-derived cell-free DNA (dd-cfDNA) shows promise as an early indicator of rejection, allowing earlier and possibly more effective treatment. This analysis was designed to assess this promise using real-world dd-cfDNA testing evidence. METHODS This retrospective analysis of the prospective, observational ProActive registry study (NCT04091984) assessed dd-cfDNA and serum creatinine levels before biopsy in 424 patients with ≥1 dd-cfDNA test (n = 1013) in the 6 mo before biopsy. RESULTS Of 4667 enrolled patients, 1631 patients had ≥18 mo of follow-up data, of which 424 had a biopsy and were included in this analysis. Twenty-six biopsies showed antibody-mediated rejection (ABMR), 62 showed T cell-mediated rejection, and 336 showed nonrejection; each from a unique patient. dd-cfDNA fractions were significantly elevated 5 mo before ABMR biopsies, and 2 mo before T cell-mediated rejection biopsies, compared with nonrejection biopsies. In contrast, serum creatinine did not discriminate between rejection and nonrejection in advance, or concurrent with biopsy. Among patients with nonrejection biopsies, estimated glomerular filtration rate was significantly lower in cases with ≥2 increased dd-cfDNA results (≥1%), compared with those with 0 or 1 increased dd-cfDNA result. CONCLUSIONS These data indicate that dd-cfDNA is an early indicator of biopsy-proven rejection, especially ABMR, suggesting a greater role for dd-cfDNA in surveillance to identify patients at high risk of ongoing or future rejection, thus requiring closer monitoring, biopsy, or other management changes.
Collapse
Affiliation(s)
- Jonathan S. Bromberg
- Department of Surgery, University of Maryland, School of Medicine, Baltimore, MD
| | | | | | | | - Erik Stites
- School of Medicine, University of Colorado Anschutz Medical Campus, Denver, CO
| | | | | | | | | | | | | | | | | | | | - Matthew Cooper
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
2
|
Napoli C, Benincasa G, Fiorelli A, Strozziero MG, Costa D, Russo F, Grimaldi V, Hoetzenecker K. Lung transplantation: Current insights and outcomes. Transpl Immunol 2024; 85:102073. [PMID: 38889844 DOI: 10.1016/j.trim.2024.102073] [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: 11/16/2023] [Revised: 06/10/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024]
Abstract
Until now, the ability to predict or retard immune-mediated rejection events after lung transplantation is still limited due to the lack of specific biomarkers. The pressing need remains to early diagnose or predict the onset of chronic lung allograft dysfunction (CLAD) and its differential phenotypes that is the leading cause of death. Omics technologies (mainly genomics, epigenomics, and transcriptomics) combined with advanced bioinformatic platforms are clarifying the key immune-related molecular routes that trigger early and late events of lung allograft rejection supporting the biomarker discovery. The most promising biomarkers came from genomics. Both unregistered and NIH-registered clinical trials demonstrated that the increased percentage of donor-derived cell-free DNA in both plasma and bronchoalveolar lavage fluid showed a good diagnostic performance for clinically silent acute rejection events and CLAD differential phenotypes. A further success arose from transcriptomics that led to development of Molecular Microscope® Diagnostic System (MMDx) to interpret the relationship between molecular signatures of lung biopsies and rejection events. Other immune-related biomarkers of rejection events may be exosomes, telomer length, DNA methylation, and histone-mediated neutrophil extracellular traps (NETs) but none of them entered in registered clinical trials. Here, we discuss novel and existing technologies for revealing new immune-mediated mechanisms underlying acute and chronic rejection events, with a particular focus on emerging biomarkers for improving precision medicine of lung transplantation field.
Collapse
Affiliation(s)
- Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", 80138 Naples, Italy; U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Clinical Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli,", Naples, Italy
| | - Giuditta Benincasa
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", 80138 Naples, Italy.
| | - Alfonso Fiorelli
- Thoracic Surgery Unit, Department of Translation Medicine, University of Campania "L. Vanvitelli", Naples, Italy
| | | | - Dario Costa
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Clinical Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli,", Naples, Italy
| | | | - Vincenzo Grimaldi
- U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, Clinical Department of Internal Medicine and Specialistics, University of Campania "L. Vanvitelli,", Naples, Italy
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| |
Collapse
|
3
|
Nikolova A, Agbor-Enoh S, Bos S, Crespo-Leiro M, Ensminger S, Jimenez-Blanco M, Minervini A, Perch M, Segovia J, Vos R, Khush K, Potena L. European Society for Organ Transplantation (ESOT) Consensus Statement on the Use of Non-invasive Biomarkers for Cardiothoracic Transplant Rejection Surveillance. Transpl Int 2024; 37:12445. [PMID: 38962472 PMCID: PMC11221358 DOI: 10.3389/ti.2024.12445] [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: 11/19/2023] [Accepted: 03/04/2024] [Indexed: 07/05/2024]
Abstract
While allograft rejection (AR) continues to threaten the success of cardiothoracic transplantation, lack of accurate and repeatable surveillance tools to diagnose AR is a major unmet need in the clinical management of cardiothoracic transplant recipients. Endomyocardial biopsy (EMB) and transbronchial biopsy (TBBx) have been the cornerstone of rejection monitoring since the field's incipience, but both suffer from significant limitations, including poor concordance of biopsy interpretation among pathologists. In recent years, novel molecular tools for AR monitoring have emerged and their performance characteristics have been evaluated in multiple studies. An international working group convened by ESOT has reviewed the existing literature and provides a series of recommendations to guide the use of these biomarkers in clinical practice. While acknowledging some caveats, the group recognized that Gene-expression profiling and donor-derived cell-free DNA (dd-cfDNA) may be used to rule out rejection in heart transplant recipients, but they are not recommended for cardiac allograft vasculopathy screening. Other traditional biomarkers (NT-proBNP, BNP or troponin) do not have sufficient evidence to support their use to diagnose AR. Regarding lung transplant, dd-cfDNA could be used to rule out clinical rejection and infection, but its use to monitor treatment response is not recommended.
Collapse
Affiliation(s)
- Andriana Nikolova
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Sean Agbor-Enoh
- Genomic Research Alliance for Transplantation (GRAfT) and Laboratory of Applied Precision Omics, National Heart, Lung, and Blood Institute (NHLBI), NIH, Bethesda, MD, United States
- Lung Transplantation, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle uponTyne, United Kingdom
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle uponTyne, United Kingdom
| | - Marisa Crespo-Leiro
- Cardiology Department, Complexo Hospitalario Universitario A Coruna (CHUAC), Instituto de Investigación Biomédica A Coruña (INIBIC), Universitade de Coruna (UDC), Centro de Investigación Biomédica en Red—Enfermedades Cardiovasculares/Network Biomedical Research Center—Cardiovascular Diseases (CIBERCV), La Coruna, Spain
| | - Stephan Ensminger
- Klinik für Herz- und Thorakale Gefäßchirurgie, Universitäres Herzzentrum Lübeck, Lübeck, Germany
| | - Marta Jimenez-Blanco
- Cardiology Department, University Hospital Ramón y Cajal (Madrid), Centro de Investigación Biomedica en Red—Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Annamaria Minervini
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation, Righospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Javier Segovia
- Cardiology Department, Puerta de Hierro Majadahonda University Hospital, Universidad Autónoma de Madrid, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana/Puerta de Hierro Health Research Institute—Segovia de Arana (IDIPHISA), Centro de Investigación Biomédica en Red—Enfermedades Cardiovasculares/Network Biomedical Research Center—Cardiovascular Diseases (CIBERCV), Madrid, Spain
| | - Robin Vos
- Department of Respiratory Diseases, UZ Leuven, and Lung Transplant Unit, Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Kiran Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Luciano Potena
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| |
Collapse
|
4
|
Calabrese DR, Shaver CM. The Emperor Has Some Clothes: Emerging Molecular Diagnostics in Post-Lung Transplant Decision-Making. Am J Respir Crit Care Med 2024; 209:1182-1184. [PMID: 38387008 PMCID: PMC11146531 DOI: 10.1164/rccm.202401-0059ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/22/2024] [Indexed: 02/24/2024] Open
Affiliation(s)
- Daniel R Calabrese
- Department of Medicine University of California, San Francisco San Francisco, California
- San Francisco Veterans Affairs Medical Center San Francisco, California
| | - Ciara M Shaver
- Department of Medicine Vanderbilt University Medical Center Nashville, Tennessee
| |
Collapse
|
5
|
Noda K, Snyder ME, Xu Q, Peters D, McDyer JF, Zeevi A, Sanchez PG. Single center study investigating the clinical association of donor-derived cell-free DNA with acute outcomes in lung transplantation. FRONTIERS IN TRANSPLANTATION 2024; 2:1339814. [PMID: 38993874 PMCID: PMC11235270 DOI: 10.3389/frtra.2023.1339814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 12/29/2023] [Indexed: 07/13/2024]
Abstract
Background Circulating donor-derived cell-free DNA (dd-cfDNA) levels have been proposed as a potential tool for the diagnosis of graft injury. In this study, we prospectively investigated dd-cfDNA plasma levels and their association with severe primary graft dysfunction (PGD) and graft rejection after lung transplant. Methods A total of 40 subjects undergoing de-novo lung transplants at our institution were recruited in this study. Blood samples were collected at various time points before and after lung transplant for 1 year. Dd-cfDNA in samples was determined using AlloSure assay (CareDx Inc.). The correlation of the value of %dd-cfDNA was investigated with the incidence of PGD, acute cellular rejection (ACR), and donor-specific antibody. Results We observed a rapid increase of %dd-cfDNA in the blood of recipients after lung transplantation compared to baseline. The levels of dd-cfDNA decreased during the first two weeks. The peak was observed within 72 h after transplantation. The peak values of %dd-cfDNA varied among subjects and did not correlate with severe PGD incidence. We observed an association between levels of %dd-cfDNA from blood collected at the time of transbronchial biopsy and the histological diagnosis of ACR at 3 weeks. Conclusion Our data show that circulating dd-cfDNA levels are associated with ACR early after transplantation but not with severe PGD. Plasma levels of dd-cfDNA may be a less invasive tool to estimate graft rejection after lung transplantation however larger studies are still necessary to better identify thresholds.
Collapse
Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mark E. Snyder
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Qingyong Xu
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, United States
| | - David Peters
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Human Genetics and Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - John F. McDyer
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Pablo G. Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| |
Collapse
|
6
|
Pradère P, Zajacova A, Bos S, Le Pavec J, Fisher A. Molecular monitoring of lung allograft health: is it ready for routine clinical use? Eur Respir Rev 2023; 32:230125. [PMID: 37993125 PMCID: PMC10663940 DOI: 10.1183/16000617.0125-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/16/2023] [Indexed: 11/24/2023] Open
Abstract
Maintenance of long-term lung allograft health in lung transplant recipients (LTRs) requires a fine balancing act between providing sufficient immunosuppression to reduce the risk of rejection whilst at the same time not over-immunosuppressing individuals and exposing them to the myriad of immunosuppressant drug side-effects that can cause morbidity and mortality. At present, lung transplant physicians only have limited and rather blunt tools available to assist them with this task. Although therapeutic drug monitoring provides clinically useful information about single time point and longitudinal exposure of LTRs to immunosuppressants, it lacks precision in determining the functional level of immunosuppression that an individual is experiencing. There is a significant gap in our ability to monitor lung allograft health and therefore tailor optimal personalised immunosuppression regimens. Molecular diagnostics performed on blood, bronchoalveolar lavage or lung tissue that can detect early signs of subclinical allograft injury, differentiate rejection from infection or distinguish cellular from humoral rejection could offer clinicians powerful tools in protecting lung allograft health. In this review, we look at the current evidence behind molecular monitoring in lung transplantation and ask if it is ready for routine clinical use. Although donor-derived cell-free DNA and tissue transcriptomics appear to be the techniques with the most immediate clinical potential, more robust data are required on their performance and additional clinical value beyond standard of care.
Collapse
Affiliation(s)
- Pauline Pradère
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Department of Respiratory Diseases, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Paris, France
| | - Andrea Zajacova
- Prague Lung Transplant Program, Department of Pneumology, Motol University Hospital and 2nd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Jérôme Le Pavec
- Department of Respiratory Diseases, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Paris, France
| | - Andrew Fisher
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| |
Collapse
|
7
|
Li Y, Liang B. Circulating donor-derived cell-free DNA as a marker for rejection after lung transplantation. Front Immunol 2023; 14:1263389. [PMID: 37885888 PMCID: PMC10598712 DOI: 10.3389/fimmu.2023.1263389] [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: 07/19/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Objective Recently, circulating donor-derive cell free DNA (dd-cfDNA) has gained growing attention in the field of solid organ transplantation. The aim of the study was to analyze circulating dd-cfDNA levels in graft rejection, ACR and AMR separately for each rejection type compared with non-rejection, and assessed the diagnostic potential of dd-cfDNA levels in predicting graft rejection after lung transplantation. Methods A systematic search for relevant articles was conducted on Medline, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang databases without restriction of languages. The search date ended on June 1, 2023. STATA software was used to analyze the difference between graft rejection, ACR, AMR and stable controls, and evaluate the diagnostic performance of circulating dd-cfDNA in detecting graft rejection. Results The results indicated that circulating dd-cfDNA levels in graft rejection, ACR, and AMR were significantly higher than non-rejection (graft rejection: SMD=1.78, 95% CI: 1.31-2.25, I2 = 88.6%, P< 0.001; ACR: SMD=1.03, 95% CI: 0.47-1.59, I2 = 89.0%, P < 0.001; AMR: SMD= 1.78, 95% CI: 1.20-2.35, I2 = 89.8%, P < 0.001). Circulating dd-cfDNA levels distinguished graft rejection from non-rejection with a pooled sensitivity of 0.87 (95% CI: 0.80-0.92) and a pooled specificity of 0.82 (95% CI: 0.76-0.86). The corresponding SROC yield an AUROC of 0.90 (95% CI: 0.87-0.93). Conclusion Circulating dd-cfDNA could be used as a non-invasive biomarker to distinguish the patients with graft rejection from normal stable controls. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023440467.
Collapse
Affiliation(s)
- Yunhui Li
- Department of Laboratory Medical Center, General Hospital of Northern Theater Command, Shenyang, China
| | - Bin Liang
- Bioinformatics of Department, Key laboratory of Cell Biology, School of Life Sciences, China Medical University, Shenyang, China
| |
Collapse
|
8
|
Trindade AJ, Chapin KC, Gray JN, Furuya Y, Mullican A, Hoy H, Demarest CT, Robbins IM, Bacchetta M, Erasmus DB, Shaver CM. Relative Change in Donor-Derived Cell-free DNA is Superior to Absolute Values for Diagnosis of Acute Lung Allograft Dysfunction. Transplant Direct 2023; 9:e1487. [PMID: 37250487 PMCID: PMC10212612 DOI: 10.1097/txd.0000000000001487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 05/31/2023] Open
Abstract
Donor-derived cell-free DNA (dd-cfDNA%) is a biomarker of early acute lung allograft dysfunction (ALAD), with a value of ≥1.0% indicating injury. Whether dd-cfDNA% is a useful biomarker in patients >2 y posttransplant is unknown. Our group previously demonstrated that median dd-cfDNA% in lung recipients ≥2 y posttransplant without ALAD was 0.45%. In that cohort, biologic variability of dd-cfDNA% was estimated by a reference change value (RCV) of 73%, suggesting that change exceeding 73% may be pathologic. In this study, we aimed to determine whether dd-cfDNA% variability or absolute thresholds are optimal for detecting ALAD. Methods We prospectively measured plasma dd-cfDNA% every 3 to 4 mo in patients ≥2 y post-lung transplant. ALAD was defined as infection, acute cellular rejection, possible antibody-mediated rejection, or change in forced expiratory volume in 1 s >10%, and was adjudicated retrospectively. We analyzed area under the curve for RCV and absolute dd-cfDNA% and reported performance of RCV ≥73% versus absolute value >1% for discriminating ALAD. Results Seventy-one patients had ≥2 baseline measurements of dd-cfDNA%; 30 developed ALAD. RCV of dd-cfDNA% at ALAD had a greater area under the receiver operator characteristic curve than absolute dd-cfDNA% values (0.87 versus 0.69, P = 0.018). Test characteristics of RCV >73% for ALAD diagnosis were sensitivity 87%, specificity 78%, positive predictive value 74%, and negative predictive value 89%. In contrast, dd-cfDNA% ≥1% had sensitivity 50%, specificity 78%, positive predictive value 63%, and negative predictive value 68%. Conclusions Relative change in dd-cfDNA% has improved test characteristics for diagnosing ALAD compared with absolute values.
Collapse
Affiliation(s)
- Anil J. Trindade
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Transplant Center, Nashville, TN
| | | | | | | | - Amy Mullican
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Haley Hoy
- Vanderbilt Transplant Center, Nashville, TN
| | - Caitlin T. Demarest
- Vanderbilt Transplant Center, Nashville, TN
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ivan M. Robbins
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Transplant Center, Nashville, TN
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN
| | - David B. Erasmus
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Transplant Center, Nashville, TN
| | - Ciara M. Shaver
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Transplant Center, Nashville, TN
| |
Collapse
|
9
|
Assessment of dd-cfDNA Levels in Clinically Stable Lung Allograft Recipients Beyond the Initial 2 y Posttransplant. Transplant Direct 2022; 8:e1411. [PMID: 36406896 PMCID: PMC9671749 DOI: 10.1097/txd.0000000000001411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 01/24/2023] Open
Abstract
UNLABELLED Donor-derived cell-free DNA (dd-cfDNA) is a useful biomarker for the diagnosis of acute allograft injury within the first 1 to 2 y after lung transplant, but its utility for diagnosing chronic lung allograft dysfunction (CLAD) has not yet been studied. Understanding baseline dd-cfDNA kinetics beyond the initial 2 y posttransplant is a necessary first step in determining the utility of dd-cfDNA as a CLAD biomarker. We seek to establish baseline dd-cfDNA% levels in clinically stable lung allograft recipients who are >2 y posttransplant. METHODS We performed a prospective, single-center, observational study to identify plasma dd-cfDNA levels in clinically stable lung allograft recipients >2 y posttransplant. RESULTS Fifty-one subjects were enrolled and ≥3 baseline dd-cfDNA measurements were acquired during a median of 252 d. The median baseline percent dd-cfDNA level in our cohort was 0.45% (interquartile range [IQR], 0.26-0.69). There were statistically significant differences in dd-cfDNA based on posttransplant duration (≤5 y posttransplant median 0.41% [IQR, 0.21-0.64] versus >5 y posttransplant median 0.50% [IQR, 0.33-0.76]; P < 0.02). However, the clinical significance of this small change in dd-cfDNA is uncertain because this magnitude of change is within the biologic test variation of 73%. CONCLUSIONS This study is the first to define levels of dd-cfDNA in clinically stable patients who are >2 y post-lung transplant. These findings lay the groundwork for the study of dd-cfDNA as a possible biomarker for CLAD.
Collapse
|
10
|
Oellerich M, Budde K, Osmanodja B, Bornemann-Kolatzki K, Beck J, Schütz E, Walson PD. Donor-derived cell-free DNA as a diagnostic tool in transplantation. Front Genet 2022; 13:1031894. [PMID: 36339004 PMCID: PMC9634115 DOI: 10.3389/fgene.2022.1031894] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/11/2022] [Indexed: 11/22/2022] Open
Abstract
There is a need to improve personalized immunosuppression in organ transplantation to reduce premature graft loss. Biomarkers are needed to better detect rejection, asymptomatic graft injury, and under-immunosuppression. Assessment of minimal necessary exposure to guide tapering and prevent immune activation is also important. There is robust clinical evidence from a large number of published studies supporting the role of dd-cfDNA for monitoring graft integrity and detection or exclusion of rejection. Dd-cfDNA indicates graft cell death without being rejection specific. It can be determined in plasma through droplet digital PCR using preselected SNPs or next generation sequencing. Changes in recipient cfDNA (e.g., by infection) can affect the results of dd-cfDNA fractional determination. This limitation can be overcome using absolute dd-cfDNA quantification. The combination of fractional and absolute determination including total cfDNA is recommended for meaningful interpretation of the results. The value proposition for the patient includes earlier transplant injury detection and intervention, less full blown rejection risk, an alternative to invasive biopsies, and personalized immunosuppression with potential for improved long-term outcome. Transplant physicians benefit from better immunosuppressive guidance and having an alternative when biopsies are refused or contraindicated. Further advantages are improved biopsy interpretation, less trial and error changes in immunosuppression, and less time dealing with complications. The laboratory medicine specialist can provide more effective services. Hospital management and insurance companies could benefit from more cost-effective surveillance of transplant recipients. Potential cost savings would result from fewer biopsies as a result of the tests’ high negative predictive value, fewer re-transplantations, and less organ failure with return to dialysis. A pathway to implementation and metrics is suggested to measure the effectiveness of dd-cfDNA testing.
Collapse
Affiliation(s)
- Michael Oellerich
- Department of Clinical Pharmacology, University Medical Center Göttingen, Göttingen, Germany
- *Correspondence: Michael Oellerich,
| | - Klemens Budde
- Department of Nephrology and Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bilgin Osmanodja
- Department of Nephrology and Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Julia Beck
- Chronix Biomedical GmbH, Göttingen, Germany
| | | | - Philip D. Walson
- Department of Clinical Pharmacology, University Medical Center Göttingen, Göttingen, Germany
| |
Collapse
|
11
|
Rosenheck J, Keller B, Fehringer G, Demko Z, Bohrade S, Ross D. Why Cell-Free DNA Can Be a “Game Changer” for Lung Allograft Monitoring for Rejection and Infection. CURRENT PULMONOLOGY REPORTS 2022; 11:75-85. [PMID: 35910533 PMCID: PMC9315332 DOI: 10.1007/s13665-022-00292-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 02/06/2023]
Abstract
Purpose of Review Although there has been improvement in short-term clinical outcomes for patients following lung transplant (LT), advances have not translated into longer-term allograft survival. Furthermore, invasive biopsies are still standard of practice for monitoring LT recipients for allograft injury. We review the relevant literature supporting the role of using plasma donor-derived cell-free DNA (dd-cfDNA) as a non-invasive biomarker for LT allograft injury surveillance and discuss future research directions. Recent Findings Accumulating data has demonstrated that dd-cfDNA is associated with molecular and cellular injury due to acute (cellular and antibody-mediated) rejection, chronic lung allograft dysfunction, and relevant infectious pathogens. Strong performance in distinguishing rejection and allograft injury from stable patients has set the stage for clinical trials to assess dd-cfDNA utility for surveillance of LT patients. Research investigating the potential role of dd-cfDNA methylation signatures to map injured tissue and cell-free DNA in detecting allograft injury-related pathogens is ongoing. Summary There is an amassed breadth of clinical data to support a role for dd-cfDNA in monitoring rejection and other forms of allograft injury. Rigorously designed, robust clinical trials that encompass the diversity in patient demographics are paramount to furthering our understanding and adoption of plasma dd-cfDNA for surveillance of lung allograft health.
Collapse
Affiliation(s)
- J.P. Rosenheck
- Division of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University, Columbus, OH USA
| | - B.C. Keller
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA USA
| | - G. Fehringer
- Medical Affairs in Organ Health, Natera, Inc., San Carlos, USA
| | - Z.P. Demko
- Medical Affairs in Organ Health, Natera, Inc., San Carlos, USA
| | - S.M. Bohrade
- Medical Affairs in Organ Health, Natera, Inc., San Carlos, USA
| | - D.J. Ross
- Medical Affairs in Organ Health, Natera, Inc., San Carlos, USA
- Lung Transplant & Molecular Diagnostics, Natera, Inc, San Carlos, CA USA
| |
Collapse
|