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Halloran PF, Reeve J, Mackova M, Madill-Thomsen KS, Demko Z, Olymbios M, Campbell P, Melenovsky V, Gong T, Hall S, Stehlik J. Comparing Plasma Donor-derived Cell-free DNA to Gene Expression in Endomyocardial Biopsies in the Trifecta-Heart Study. Transplantation 2024; 108:1931-1942. [PMID: 38538559 PMCID: PMC11335077 DOI: 10.1097/tp.0000000000004986] [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: 11/30/2023] [Revised: 01/19/2024] [Accepted: 02/05/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Plasma donor-derived cell-free DNA (dd-cfDNA) is used to screen for rejection in heart transplants. We launched the Trifecta-Heart study ( ClinicalTrials.gov No. NCT04707872), an investigator-initiated, prospective trial, to examine the correlations between genome-wide molecular changes in endomyocardial biopsies (EMBs) and plasma dd-cfDNA. The present report analyzes the correlation of plasma dd-cfDNA with gene expression in EMBs from 4 vanguard centers and compared these correlations with those in 604 kidney transplant biopsies in the Trifecta-Kidney study ( ClinicalTrials.gov No. NCT04239703). METHODS We analyzed 137 consecutive dd-cfDNA-EMB pairs from 70 patients. Plasma %dd-cfDNA was measured by the Prospera test (Natera Inc), and gene expression in EMBs was assessed by Molecular Microscope Diagnostic System using machine-learning algorithms to interpret rejection and injury states. RESULTS Top transcripts correlating with dd-cfDNA were related to genes increased in rejection such as interferon gamma-inducible genes (eg, HLA-DMA ) but also with genes induced by injury and expressed in macrophages (eg, SERPINA1 and HMOX1 ). In gene enrichment analysis, the top dd-cfDNA-correlated genes reflected inflammation and rejection pathways. Dd-cfDNA correlations with rejection genes in EMB were similar to those seen in kidney transplant biopsies, with somewhat stronger correlations for TCMR genes in hearts and ABMR genes in kidneys. However, the correlations with parenchymal injury-induced genes and macrophage genes were much stronger in hearts. CONCLUSIONS In this first analysis of Trifecta-Heart study, dd-cfDNA correlates significantly with molecular rejection but also with injury and macrophage infiltration, reflecting the proinflammatory properties of injured cardiomyocytes. The relationship supports the utility of dd-cfDNA in clinical management of heart transplant recipients.
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Affiliation(s)
- Philip F. Halloran
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
| | - Jeff Reeve
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
| | - Martina Mackova
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
| | - Katelynn S. Madill-Thomsen
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
| | | | | | | | | | | | | | - Josef Stehlik
- Department of Internal Medicine, University of Utah, Salt Lake City, UT
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Khush K, Hall S, Kao A, Raval N, Dhingra R, Shah P, Bellumkonda L, Ravichandran A, Van Bakel A, Uriel N, Patel S, Pinney S, DePasquale E, Baran DA, Pinney K, Oreschak K, Kobulnik J, Shen L, Teuteberg J. Surveillance with dual noninvasive testing for acute cellular rejection after heart transplantation: Outcomes from the Surveillance HeartCare Outcomes Registry. J Heart Lung Transplant 2024; 43:1409-1421. [PMID: 38759766 DOI: 10.1016/j.healun.2024.05.003] [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: 02/06/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Molecular testing with gene-expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA) is increasingly used in the surveillance for acute cellular rejection (ACR) after heart transplant. However, the performance of dual testing over each test individually has not been established. Further, the impact of dual noninvasive surveillance on clinical decision-making has not been widely investigated. METHODS We evaluated 2,077 subjects from the Surveillance HeartCare Outcomes Registry registry who were enrolled between 2018 and 2021 and had verified biopsy data and were categorized as dual negative, GEP positive/dd-cfDNA negative, GEP negative/dd-cfDNA positive, or dual positive. The incidence of ACR and follow-up testing rates for each group were evaluated. Positive likelihood ratios (LRs+) were calculated, and biopsy rates over time were analyzed. RESULTS The incidence of ACR was 1.5% for dual negative, 1.9% for GEP positive/dd-cfDNA negative, 4.3% for GEP negative/dd-cfDNA positive, and 9.2% for dual-positive groups. Follow-up biopsies were performed after 8.8% for dual negative, 14.2% for GEP positive/dd-cfDNA negative, 22.8% for GEP negative/dd-cfDNA positive, and 35.4% for dual-positive results. The LR+ for ACR was 1.37, 2.91, and 3.90 for GEP positive, dd-cfDNA positive, and dual-positive testing, respectively. From 2018 to 2021, biopsies performed between 2 and 12-months post-transplant declined from 5.9 to 5.3 biopsies/patient, and second-year biopsy rates declined from 1.5 to 0.9 biopsies/patient. At 2 years, survival was 94.9%, and only 2.7% had graft dysfunction. CONCLUSIONS Dual molecular testing demonstrated improved performance for ACR surveillance compared to single molecular testing. The use of dual noninvasive testing was associated with lower biopsy rates over time, excellent survival, and low incidence of graft dysfunction.
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Affiliation(s)
- Kiran Khush
- Divison of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Shelley Hall
- Department of Cardiology, Baylor University Medical Center, Dallas, Texas
| | - Andrew Kao
- Division of Cardiology, St. Luke's Health System Kansas City Mid America Heart Institute, Kansas City, Missouri
| | - Nirav Raval
- Transplant Institute, AdventHealth Transplant Institute, Orlando, Florida
| | - Ravi Dhingra
- Advanced Heart Failure and Transplant Program, Froedtert and Medical College of Wisconsin, University of Wisconsin-Madison, Madison, Wisconsin
| | - Palak Shah
- Cardiovascular Genomics Center, Inova Heart and Vascular Institute, Fairfax, Virginia
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ashwin Ravichandran
- Advanced Heart Failure and Transplant Cardiology, St Vincent Heart Center, Indianapolis, Indiana
| | - Adrian Van Bakel
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Nir Uriel
- Department of Cardiology, New York Presbyterian, New York, New York
| | - Snehal Patel
- Cardiology Division, Montefiore-Einstein, Bronx, New York
| | - Sean Pinney
- Department of Cardiology, Mount Sinai Morningside, New York, New York
| | - Eugene DePasquale
- Heart Failure, Heart Transplantation and Mechanical Circulatory Support, University of Southern California, Los Angeles, California
| | - David A Baran
- Advanced Heart Failure, Transplant and Mechanical Circulatory Support, Cleveland Clinic Florida, Westin, Florida
| | | | | | | | - Ling Shen
- Biostatistics, CareDx, Brisbane, California
| | - Jeffrey Teuteberg
- Divison of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California.
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Alharethi R, Knight S, Luikart HI, Wolf-Doty T, Bride DL, Kim DT, Khush KK. Lack of Association Between Donor-Derived Cell-Free DNA and Cardiac Allograft Vasculopathy. Clin Transplant 2024; 38:e15416. [PMID: 39058520 DOI: 10.1111/ctr.15416] [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: 01/26/2024] [Revised: 06/09/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024]
Abstract
Cardiac allograft vasculopathy (CAV) is a leading cause of death after heart transplantation (HT). We evaluated donor-derived cell-free DNA (dd-cfDNA) as a noninvasive biomarker of CAV development after HT. The INSPIRE registry at the Intermountain Medical Center was queried for stored plasma samples from HT patients with and without CAV. At Stanford University, HT patients with CAV (cases) and without CAV (controls) were enrolled prospectively, and blood samples were collected. All the samples were analyzed for dd-cfDNA using the AlloSure assay (CareDx, Inc.). CAV was defined per the ISHLT 2010 standardized classification system. Univariate associations between patient demographics and clinical characteristics and their CAV grade were tested using chi-square and Wilcoxon rank sum tests. Associations between their dd-cfDNA levels and CAV grades were examined using a nonparametric Kruskal-Wallis test. A total of 69 pts were included, and 101 samples were analyzed for dd-cfDNA. The mean age at sample collection was 58.6 ± 13.7 years; 66.7% of the patients were male, and 81% were White. CAV 0, 1, 2, and 3 were present in 37.6%, 22.8%, 22.8%, and 16.8% of included samples, respectively. The median dd-cfDNA level was 0.13% (0.06, 0.33). The median dd-cfDNA level was not significantly different between CAV (-) and CAV (+): 0.09% (0.05%-0.32%) and 0.15% (0.07%-0.33%), respectively, p = 0.25 and with similar results across all CAV grades. In our study, dd-cfDNA levels did not correlate with the presence of CAV and did not differ across CAV grades. As such, dd-cfDNA does not appear to be a reliable noninvasive biomarker for CAV surveillance.
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Affiliation(s)
- Rami Alharethi
- Cardiovascular Medicine, Intermountain Medical Center, Murray, Utah, USA
| | - Stacey Knight
- Cardiovascular Medicine, Intermountain Medical Center, Murray, Utah, USA
| | - Helen I Luikart
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Daniel L Bride
- Cardiovascular Medicine, Intermountain Medical Center, Murray, Utah, USA
| | - Daniel T Kim
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
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DeFilippis EM, Sweigart B, Khush KK, Shah P, Agbor-Enoh S, Valantine HA, Vest AR. Sex-specific patterns of donor-derived cell-free DNA in heart transplant rejection: An analysis from the Genomic Research Alliance for Transplantation (GRAfT). J Heart Lung Transplant 2024; 43:1135-1141. [PMID: 38460620 PMCID: PMC11144097 DOI: 10.1016/j.healun.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 01/22/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND Noninvasive methods for surveillance of acute rejection are increasingly used in heart transplantation (HT), including donor-derived cell-free DNA (dd-cfDNA). As other cardiac biomarkers differ by sex, we hypothesized that there may be sex-specific differences in the performance of dd-cfDNA for the detection of acute rejection. The purpose of the current study was to examine patterns of dd-cfDNA seen in quiescence and acute rejection in male and female transplant recipients. METHODS Patients enrolled in the Genomic Research Alliance for Transplantation who were ≥18 years at the time of HT were included. Rejection was defined by endomyocardial biopsy with acute cellular rejection (ACR) grade ≥2R and/or antibody-mediated rejection ≥ pAMR 1. dd-cfDNA was quantitated using shotgun sequencing. Median dd-cfDNA levels were compared between sexes during quiescence and rejection. The performance of dd-cfDNA by sex was assessed using area under the receiver operator characteristic (AUROC) curve. Allograft injury was defined as dd-cfDNA ≥0.25%. RESULTS One hundred fifty-one unique patients (49 female, 32%) were included in the analysis with 1,119 available dd-cfDNA measurements. Baseline characteristics including demographics and comorbidities were not significantly different between sexes. During quiescence, there were no significant sex differences in median dd-cfDNA level (0.04% [IQR 0.00, 0.16] in females vs 0.03% [IQR 0.00, 0.12] in males, p = 0.22). There were no significant sex differences in median dd-cfDNA for ACR (0.33% [0.21, 0.36] in females vs 0.32% [0.21, 1.10] in males, p = 0.57). Overall, median dd-cfDNA levels were higher in antibody-mediated rejection (AMR) than ACR but did not significantly differ by sex (0.50% [IQR 0.18, 0.82] in females vs 0.63% [IQR 0.32, 1.95] in males, p = 0.51). Elevated dd-cfDNA detected ACR/AMR with an AUROC of 0.83 in females and 0.89 in males, p-value for comparison = 0.16. CONCLUSIONS There were no significant sex differences in dd-cfDNA levels during quiescence and rejection. Performance characteristics were similar, suggesting similar diagnostic thresholds can be used in men and women for rejection surveillance.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York
| | - Benjamin Sweigart
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, Massachusetts
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Palak Shah
- Heart Failure, Mechanical Circulatory Support and Transplant, Inova Schar Heart and Vascular, Falls Church, Virginia
| | - Sean Agbor-Enoh
- Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Hannah A Valantine
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Amanda R Vest
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts.
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Lee DH, Usmani A, Wu R, Wicks T, Noh CY, Burke R, Ravichandran V, Wolf-Doty T, Dumitru I, Oliveira GH, Berman P, Mackie B. Relationship between donor-derived cell-free DNA and tissue-based rejection-related transcripts in heart transplantation. J Heart Lung Transplant 2024; 43:1118-1125. [PMID: 38373559 DOI: 10.1016/j.healun.2024.02.011] [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: 04/07/2023] [Revised: 01/30/2024] [Accepted: 02/13/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Endomyocardial biopsy (EMB)-based traditional microscopy remains the gold standard for the detection of cardiac allograft rejection, despite its limitation of inherent subjectivity leading to inter-reader variability. Alternative techniques now exist to surveil for allograft injury and classify rejection. Donor-derived cell-free DNA (dd-cfDNA) testing is now a validated blood-based assay used to surveil for allograft injury. The molecular microscope diagnostic system (MMDx) utilizes intragraft rejection-associated transcripts (RATs) to classify allograft rejection and identify injury. The use of dd-cfDNA and MMDx together provides objective molecular insight into allograft injury and rejection. The aim of this study was to measure the diagnostic agreement between dd-cfDNA and MMDx and assess the relationship between dd-cfDNA and MMDx-derived RATs, which may provide further insight into the pathophysiology of allograft rejection and injury. METHODS This is a retrospective observational study of 156 EMB evaluated with traditional microscopy and MMDx. All samples were paired with dd-cfDNA from peripheral blood before EMB (up to 9 days). Diagnostic agreement between traditional histopathology, MMDx, and dd-cfDNA (threshold of 0.20%) was compared for assessment of allograft injury. In addition, the relationship between dd-cfDNA and individual RAT expression levels from MMDx was evaluated. RESULTS MMDx characterized allograft tissue as no rejection (62.8%), antibody-mediated rejection (ABMR) (26.9%), T-cell-mediated rejection (TCMR) (5.8%), and mixed ABMR/TCMR (4.5%). For the diagnosis of any type of rejection (TCMR, ABMR, and mixed rejection), there was substantial agreement between MMDx and dd-cfDNA (76.3% agreement). All transcript clusters (group of gene sets designated by MMDx) and individual transcripts considered abnormal from MMDx had significantly elevated dd-cfDNA. In addition, a positive correlation between dd-cfDNA levels and certain MMDx-derived RATs was observed. Tissue transcript clusters were correlated with dd-cfDNA scores, including DSAST, GRIT, HT1, QCMAT, and S4. For individual transcripts, tissue ROBO4 was significantly correlated with dd-cfDNA in both nonrejection and rejection as assessed by MMDx. CONCLUSIONS Collectively, we have shown substantial diagnostic agreement between dd-cfDNA and MMDx. Furthermore, based on the findings presented, we postulate a common pathway between the release of dd-cfDNA and expression of ROBO4 (a vascular endothelial-specific gene that stabilizes the vasculature) in the setting of antibody-mediated rejection, which may provide a mechanistic rationale for observed elevations in dd-cfDNA in AMR, compared to acute cellular rejection.
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Affiliation(s)
- Dae Hyun Lee
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Division of Cardiovascular Medicine, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida; Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida.
| | - Ahsan Usmani
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Robby Wu
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Division of Cardiovascular Medicine, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida; Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida
| | - Tammi Wicks
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida
| | - Caroline Y Noh
- Department of Pediatrics, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | | | | | | | - Ioana Dumitru
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Division of Cardiovascular Medicine, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida; Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida
| | - Guilherme H Oliveira
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Division of Cardiovascular Medicine, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida; Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida
| | - Peter Berman
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Division of Cardiovascular Medicine, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida; Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida
| | - Benjamin Mackie
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Division of Cardiovascular Medicine, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida; Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida.
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Moayedi Y, Teuteberg JJ. Rejection Surveillance After Heart Transplantation: Is Paired Noninvasive Testing the New Gold Standard? Transplantation 2024:00007890-990000000-00803. [PMID: 38946033 DOI: 10.1097/tp.0000000000005113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Rejection surveillance after heart transplantation has traditionally relied on numerous endomyocardial biopsies, most of which occur during the first posttransplant year. With the introduction of gene expression profiling and, more recently, donor-derived cell-free DNA, a great proportion of surveillance is being performed noninvasively with both tests. Although patients have welcomed the use of paired testing because of the decreased risk and inconvenience, interpretation of both tests can sometimes be challenging, particularly when the test results are discordant. Growing evidence from both single-center experiences and large national databases has given insights that have allowed the field to operationalize dual testing and provide physicians with algorithms to approach paired testing. The increased use of noninvasive testing has also begun to challenge the role of biopsy as the gold standard for graft monitoring, not only for rejection but over the life of the heart transplant. In a growing number of circumstances, cell-free DNA not only may be a better means of assessing rejection but could also redefine how clinicians approach the diagnosis and even treatment of graft injury. As the heart transplant community garners more experience and generates more data, the current paradigms of heart transplant surveillance will continue to be challenged.
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Affiliation(s)
- Yasbanoo Moayedi
- Ted Rogers Centre for Heart Research, Ajmera Transplant Centre, University of Toronto, Toronto, ON, Canada
- Ajmera Transplant Centre, University of Toronto, Toronto, ON, Canada
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Fernandez Valledor A, Moeller CM, Rubinstein G, Rahman S, Oren D, Baranowska J, Lee C, Salazar R, Hennecken C, Rahman A, Elad B, Lotan D, DeFilippis EM, Yunis A, Fried J, Raihkelkar J, Oh KT, Bae D, Lin E, Lee SH, Regan M, Yuzelpolskaya M, Colombo P, Majure DT, Latif F, Clerkin KD, Sayer GT, Uriel N. Clinical Utility of the Molecular Microscope Diagnostic System in a Real-World Transplant Cohort: Moving Towards a New Paradigm. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.24.24309444. [PMID: 38978641 PMCID: PMC11230306 DOI: 10.1101/2024.06.24.24309444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Objectives To evaluate the clinical implications of adjunctive molecular gene expression analysis (MMDx ) of biopsy specimens in heart transplant (HT ) recipients with suspected rejection. Introduction Histopathological evaluation remains the standard method for rejection diagnosis in HT. However, the wide interobserver variability combined with a relatively common incidence of "biopsy-negative" rejection has raised concerns about the likelihood of false-negative results. MMDx, which uses gene expression to detect early signs of rejection, is a promising test to further refine the assessment of HT rejection. Methods Single-center prospective study of 418 consecutive for-cause endomyocardial biopsies performed between November 2022 and May 2024. Each biopsy was graded based on histology and assessed for rejection patterns using MMDx. MMDx results were deemed positive if borderline or definitive rejection was present. The impact of MMDx results on clinical management was evaluated. Primary outcomes were 1-year survival and graft dysfunction following MMDx-guided clinical management. Secondary outcomes included changes in donor-specific antibodies, MMDx gene transcripts, and donor-derived cell-free DNA (dd-cfDNA) levels. Results We analyzed 418 molecular samples from 237 unique patients. Histology identified rejection in 32 cases (7.7%), while MMDx identified rejection in 95 cases (22.7%). Notably, in 79 of the 95 cases where MMDx identified rejection, histology results were negative, with the majority of these cases being antibody-mediated rejection (62.1%). Samples with rejection on MMDx were more likely to show a combined elevation of dd-cfDNA and peripheral blood gene expression profiling than those with borderline or negative MMDx results (36.7% vs 28.0% vs 10.3%; p<0.001). MMDx results led to the implementation of specific antirejection protocols or changes in immunosuppression in 20.4% of cases, and in 73.4% of cases where histology was negative and MMDx showed rejection. 1-year survival was better in the positive MMDx group where clinical management was guided by MMDx results (87.0% vs 78.6%; log rank p=0.0017). Conclusions In our cohort, MMDx results more frequently indicated rejection than histology, often leading to the initiation of antirejection treatment. Intervention guided by positive MMDx results was associated with improved outcomes. Graphical abstract
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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.
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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
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9
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Urie RR, Morris A, Farris D, Hughes E, Xiao C, Chen J, Lombard E, Feng J, Li JZ, Goldstein DR, Shea LD. Biomarkers from subcutaneous engineered tissues predict acute rejection of organ allografts. SCIENCE ADVANCES 2024; 10:eadk6178. [PMID: 38748794 PMCID: PMC11095459 DOI: 10.1126/sciadv.adk6178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 04/10/2024] [Indexed: 05/19/2024]
Abstract
Invasive graft biopsies assess the efficacy of immunosuppression through lagging indicators of transplant rejection. We report on a microporous scaffold implant as a minimally invasive immunological niche to assay rejection before graft injury. Adoptive transfer of T cells into Rag2-/- mice with mismatched allografts induced acute cellular allograft rejection (ACAR), with subsequent validation in wild-type animals. Following murine heart or skin transplantation, scaffold implants accumulate predominantly innate immune cells. The scaffold enables frequent biopsy, and gene expression analyses identified biomarkers of ACAR before clinical signs of graft injury. This gene signature distinguishes ACAR and immunodeficient respiratory infection before injury onset, indicating the specificity of the biomarkers to differentiate ACAR from other inflammatory insult. Overall, this implantable scaffold enables remote evaluation of the early risk of rejection, which could potentially be used to reduce the frequency of routine graft biopsy, reduce toxicities by personalizing immunosuppression, and prolong transplant life.
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Affiliation(s)
- Russell R. Urie
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Aaron Morris
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Diana Farris
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Elizabeth Hughes
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Chengchuan Xiao
- Department of Molecular, Cellular, and Developmental Biology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Judy Chen
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Program in Immunology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Elizabeth Lombard
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jiane Feng
- Animal Phenotyping Core, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jun Z. Li
- Department of Human Genetics, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI 48109, USA
| | - Daniel R. Goldstein
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Program in Immunology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Lonnie D. Shea
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
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10
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Pérez-Carrillo L, Giménez-Escamilla I, González-Torrent I, Delgado-Arija M, Sánchez-Lázaro I, García-Manzanares M, Martínez-Dolz L, Portolés M, Tarazón E, Roselló-Lletí E. Circulating long non-coding RNAs detection after heart transplantation and its accuracy in the diagnosis of acute cardiac rejection. Biomark Res 2024; 12:49. [PMID: 38735964 PMCID: PMC11089702 DOI: 10.1186/s40364-024-00590-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 04/04/2024] [Indexed: 05/14/2024] Open
Abstract
Long non-coding RNAs (lncRNAs) are closely implicated in biological processes and diseases with high inflammatory components. These molecules exhibit significant temporal and tissue specificity. However, the expression and function of lncRNAs have not been studied in patients after heart transplantation. Thus, we aimed to identify circulating lncRNAs in these patients and evaluate their diagnostic capacity as potential biomarkers for the non-invasive detection of acute cellular rejection (ACR). For them, we performed a transcriptomic study based on ncRNA-seq technology to detect lncRNAs in serum samples, matched to routine endomyocardial biopsies, from patients without rejection episode (0R, n = 12) and with mild (1R, n = 16) or moderate-severe (≥ 2R, n = 12) ACR. We identified 11,062 circulating lncRNAs in the serum of patients after heart transplantation. Moreover, 6 lncRNAs showed statistically significant expression when the different ACR grades were compared. Among them, AC008105.3, AC006525.1, AC011455.8, AL359220.1, and AC025279.1 had relevant diagnostic capacity for detection of ≥ 2R (AUC of 0.850 to 1.000) and 1R (AUC of 0.750 to 0.854) grades, along with high specificity and positive predictive values (≥ 83%). In addition, AL359220.1 and AC025279.1 were independent predictors for the presence of moderate-severe ACR (odds ratio = 31.132, p < 0.01 and C statistic = 0.939, p < 0.0001; odds ratio = 18.693, p < 0.05 and C statistic = 0.902, p < 0.001; respectively). In conclusion, we describe, for the first time, circulating lncRNAs after heart transplantation as potential candidates for non-invasive detection of ACR. AL359220.1 and AC025279.1 showed excellent diagnostic capability correlating with the severity episode and were strong independent predictors of rejection.
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Affiliation(s)
- Lorena Pérez-Carrillo
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IISLaFe), Valencia, Spain
- CIBERCV, Madrid, Spain
| | - Isaac Giménez-Escamilla
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IISLaFe), Valencia, Spain
- CIBERCV, Madrid, Spain
| | - Irene González-Torrent
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IISLaFe), Valencia, Spain
| | - Marta Delgado-Arija
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IISLaFe), Valencia, Spain
- CIBERCV, Madrid, Spain
| | - Ignacio Sánchez-Lázaro
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IISLaFe), Valencia, Spain
- CIBERCV, Madrid, Spain
- Heart Failure and Transplantation Unit, Cardiology Department, University and Polytechnic La Fe Hospital, Valencia, Spain
| | - María García-Manzanares
- CIBERCV, Madrid, Spain
- Department of Animal Medicine and Surgery, Veterinary Faculty, CEU Cardenal Herrera University, Valencia, Spain
| | - Luis Martínez-Dolz
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IISLaFe), Valencia, Spain
- CIBERCV, Madrid, Spain
- Heart Failure and Transplantation Unit, Cardiology Department, University and Polytechnic La Fe Hospital, Valencia, Spain
| | - Manuel Portolés
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IISLaFe), Valencia, Spain
- CIBERCV, Madrid, Spain
| | - Estefanía Tarazón
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IISLaFe), Valencia, Spain.
- CIBERCV, Madrid, Spain.
| | - Esther Roselló-Lletí
- Clinical and Translational Research in Cardiology Unit, Health Research Institute Hospital La Fe (IISLaFe), Valencia, Spain.
- CIBERCV, Madrid, Spain.
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11
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Deshpande SR, Zangwill SD, Richmond ME, Kindel SJ, Schroder JN, Gaglianello N, Bichell DP, Wigger MA, Knecht KR, Thrush PT, Mahle WT, North PE, Simpson PM, Zhang L, Dasgupta M, Tomita-Mitchell A, Mitchell ME. Evaluating threshold for donor fraction cell-free DNA using clinically available assay for rejection in pediatric and adult heart transplantation. Pediatr Transplant 2024; 28:e14708. [PMID: 38553812 PMCID: PMC10987078 DOI: 10.1111/petr.14708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 01/10/2024] [Accepted: 01/23/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND The aims of the study were to assess the performance of a clinically available cell-free DNA (cfDNA) assay in a large cohort of pediatric and adult heart transplant recipients and to evaluate performance at specific cut points in detection of rejection. METHODS Observational, non-interventional, prospective study enrolled pediatric and adult heart transplant recipients from seven centers. Biopsy-associated plasma samples were used for cfDNA measurements. Pre-determined cut points were tested for analytic performance. RESULTS A total of 487 samples from 160 subjects were used for the analysis. There were significant differences for df-cfDNA values between rejection [0.21% (IQR 0.12-0.69)] and healthy samples [0.05% (IQR 0.01-0.14), p < .0001]. The pediatric rejection group had a median df-cfDNA value of 0.93% (IQR 0.28-2.84) compared to 0.09% (IQR 0.04-0.23) for healthy samples, p = .005. Overall negative predictive value was 0.94 while it was 0.99 for pediatric patients. Cut points of 0.13% and 0.15% were tested for various types of rejection profiles and were appropriate to rule out rejection. CONCLUSION The study suggests that pediatric patients with rejection show higher levels of circulating df-cfDNA compared to adults and supports the specific cut points for clinical use in pediatric and adult patients with overall acceptable performance.
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Affiliation(s)
- Shriprasad R Deshpande
- Division of Pediatric Cardiology, Children's National Heart Institute, Children's National Hospital, Washington, DC, USA
| | - Steven D Zangwill
- Division of Cardiology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Marc E Richmond
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Nunzio Gaglianello
- Division of Cardiology, Department of Medicine, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Mark A Wigger
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Kenneth R Knecht
- Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Phillip T Thrush
- Department of Cardiology, Lurie Children's Hospital, Chicago, Illinois, USA
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Paula E North
- Department of Pathology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pippa M Simpson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liyun Zhang
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mahua Dasgupta
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aoy Tomita-Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wisconsin, USA
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin, USA
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12
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Cusi V, Vaida F, Wettersten N, Rodgers N, Tada Y, Gerding B, Urey MA, Greenberg B, Adler ED, Kim PJ. Incidence of Acute Rejection Compared With Endomyocardial Biopsy Complications for Heart Transplant Patients in the Contemporary Era. Transplantation 2024; 108:1220-1227. [PMID: 38098137 DOI: 10.1097/tp.0000000000004882] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND The reference standard of detecting acute rejection (AR) in adult heart transplant (HTx) patients is an endomyocardial biopsy (EMB). The majority of EMBs are performed in asymptomatic patients. However, the incidence of treated AR compared with EMB complications has not been compared in the contemporary era (2010-current). METHODS The authors retrospectively analyzed 2769 EMBs obtained in 326 consecutive HTx patients between August 2019 and August 2022. Variables included surveillance versus for-cause indication, recipient and donor characteristics, EMB procedural data and pathological grades, treatment for AR, and clinical outcomes. RESULTS The overall EMB complications rate was 1.6%. EMBs performed within 1 mo after HTx compared with after 1 mo from HTx showed significantly increased complications (OR, 12.74, P < 0.001). The treated AR rate was 14.2% in the for-cause EMBs and 1.2% in the surveillance EMBs. We found the incidence of AR versus EMB complications was significantly lower in the surveillance compared with the for-cause EMB group (OR, 0.05, P < 0.001). We also found the incidence of EMB complications was higher than treated AR in surveillance EMBs. CONCLUSIONS The yield of surveillance EMBs has declined in the contemporary era, with a higher incidence of EMB complications compared with detected AR. The risk of EMB complications was highest within 1 mo after HTx. Surveillance EMB protocols in the contemporary era may need to be reevaluated.
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Affiliation(s)
| | - Florin Vaida
- Department of Family Medicine and Public Health, UC San Diego, La Jolla, CA
| | - Nicholas Wettersten
- Cardiology Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
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13
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Casas S, Tangprasertchai NS, Oikonomaki K, Mathers S, Sollet ZC, Samara S, Liu J, Burlinson ND, Constantoulakis P, Villard J, Viard T. Multi-centre analytical performance verification of an IVD assay to quantify donor-derived cell-free DNA in solid organ transplant recipients. HLA 2024; 103:e15518. [PMID: 38733247 DOI: 10.1111/tan.15518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/19/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024]
Abstract
Donor-derived cell-free DNA (dd-cfDNA) has been widely studied as biomarker for non-invasive allograft rejection monitoring. Earlier rejection detection enables more prompt diagnosis and intervention, ultimately improving patient treatment and outcomes. This multi-centre study aims to verify analytical performance of a next-generation sequencing-based dd-cfDNA assay at end-user environments. Three independent laboratories received the same experimental design and 16 blinded samples to perform cfDNA extraction and the dd-cfDNA assay workflow. dd-cfDNA results were compared between sites and against manufacturer validation to evaluate concordance, reproducibility, repeatability and verify analytical performance. A total of 247 sample libraries were generated across 18 runs, with completion time of <24 h. A 96.0% first pass rate highlighted minimal failures. Overall observed versus expected dd-cfDNA results demonstrated good concordance and a strong positive correlation with linear least squares regression r2 = 0.9989, and high repeatability and reproducibility within and between sites, respectively (p > 0.05). Manufacturer validation established limit of blank 0.18%, limit of detection 0.23% and limit of quantification 0.23%, and results from independent sites verified those limits. Parallel analyses illustrated no significant difference (p = 0.951) between dd-cfDNA results with or without recipient genotype. The dd-cfDNA assay evaluated here has been verified as a reliable method for efficient, reproducible dd-cfDNA quantification in plasma from solid organ transplant recipients without requiring genotyping. Implementation of onsite dd-cfDNA testing at clinical laboratories could facilitate earlier detection of allograft injury, bearing great potential for patient care.
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Affiliation(s)
| | | | | | - Simon Mathers
- Transplantation Laboratory, Manchester University NHS Foundation Trust, Manchester, UK
| | - Zuleika Calderin Sollet
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Geneva University Hospitals, Geneva, Switzerland
| | | | - June Liu
- CareDx, Brisbane, California, USA
| | | | | | - Jean Villard
- Transplantation Immunology Unit and National Reference Laboratory for Histocompatibility, Geneva University Hospitals, Geneva, Switzerland
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14
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O'Halloran CP, Tannous P, Arva NC, Thrush PT, Monge M, Joong A, Magnetta DA. Histopathology, mRNA expression profile, and donor-derived cell-free DNA for assessment of rejection in pediatric heart transplantation. Pediatr Transplant 2024; 28:e14705. [PMID: 38528753 DOI: 10.1111/petr.14705] [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: 10/29/2023] [Revised: 01/10/2024] [Accepted: 01/23/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND The relationship between histopathologic and molecular ("MMDx"®) assessments of endomyocardial biopsy (EMB) and serum donor-derived cell-free DNA (ddcfDNA) in acute rejection (AR) assessment following pediatric heart transplantation (HT) is unknown. METHODS EMB sent for MMDx and histopathology from November 2021 to September 2022 were reviewed. MMDx and histopathology results were compared. DdcfDNA obtained ≤1 week prior to EMB were compared with histopathology and MMDx results. The discrimination of ddcfDNA for AR was assessed using receiver-operating curves. FINDINGS In this study, 177 EMBs were obtained for histopathology and MMDx, 101 had time-matched ddcfDNA values. MMDx and Histopathology displayed moderate agreement for T-cell-mediated rejection (TCMR, Kappa = 0.52, p < .001) and antibody-mediated rejection (ABMR, Kappa = 0.41, p < .001). Discordant results occurred in 24% of cases, most often with ABMR. Compared with no AR, ddcfDNA values were elevated in cases of AR diagnosed by both histopathology and MMDx (p < .01 for all). Additionally, ddcfDNA values were elevated in injury patterns on MMDx, even when AR was not present (p = .01). DdcfDNA displayed excellent discrimination (AUC 0.83) for AR by MMDx and/or histopathology. Using a threshold of ≥0.135%, ddcfDNA had a sensitivity of 90%, specificity of 63%, PPV of 52%, and NPV of 94%. CONCLUSIONS Histopathology and MMDx displayed moderate agreement in diagnosing AR following pediatric HT, with most discrepancies noted in the presence of ABMR. DdcfDNA is elevated with AR, with excellent discrimination and high NPV particularly when utilizing MMDx. A combination of all three tests may be necessary in some cases.
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Affiliation(s)
- Conor P O'Halloran
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Paul Tannous
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nicoleta C Arva
- Department of Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Philip T Thrush
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael Monge
- Division of Cardiovascular Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Anna Joong
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Defne A Magnetta
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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15
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McNamara ME, Jain SS, Oza K, Muralidaran V, Kiliti AJ, McDeed AP, Patil D, Cui Y, Schmidt MO, Riegel AT, Kroemer AH, Wellstein A. Circulating, cell-free methylated DNA indicates cellular sources of allograft injury after liver transplant. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.04.588176. [PMID: 38617373 PMCID: PMC11014558 DOI: 10.1101/2024.04.04.588176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Post-transplant complications reduce allograft and recipient survival. Current approaches for detecting allograft injury non-invasively are limited and do not differentiate between cellular mechanisms. Here, we monitor cellular damages after liver transplants from cell-free DNA (cfDNA) fragments released from dying cells into the circulation. We analyzed 130 blood samples collected from 44 patients at different time points after transplant. Sequence-based methylation of cfDNA fragments were mapped to patterns established to identify cell types in different organs. For liver cell types DNA methylation patterns and multi-omic data integration show distinct enrichment in open chromatin and regulatory regions functionally important for the respective cell types. We find that multi-tissue cellular damages post-transplant recover in patients without allograft injury during the first post-operative week. However, sustained elevation of hepatocyte and biliary epithelial cfDNA beyond the first week indicates early-onset allograft injury. Further, cfDNA composition differentiates amongst causes of allograft injury indicating the potential for non-invasive monitoring and timely intervention.
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Affiliation(s)
- Megan E. McNamara
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Sidharth S. Jain
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Kesha Oza
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC, USA
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Vinona Muralidaran
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Amber J. Kiliti
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - A. Patrick McDeed
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Digvijay Patil
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Yuki Cui
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Marcel O. Schmidt
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Anna T. Riegel
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Alexander H.K. Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Anton Wellstein
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
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16
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Gauthier PT, Madill-Thomsen KS, Demko Z, Prewett A, Gauthier P, Halloran PF. Distinct Molecular Processes Mediate Donor-derived Cell-free DNA Release From Kidney Transplants in Different Disease States. Transplantation 2024; 108:898-910. [PMID: 38150492 PMCID: PMC10962427 DOI: 10.1097/tp.0000000000004877] [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: 08/07/2023] [Revised: 10/05/2023] [Accepted: 10/23/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Among all biopsies in the Trifecta-Kidney Study ( ClinicalTrials.gov NCT04239703), elevated plasma donor-derived cell-free DNA (dd-cfDNA) correlated most strongly with molecular antibody-mediated rejection (AMR) but was also elevated in other states: T cell-mediated rejection (TCMR), acute kidney injury (AKI), and some apparently normal biopsies. The present study aimed to define the molecular correlates of plasma dd-cfDNA within specific states. METHODS Dd-cfDNA was measured by the Prospera test. Molecular rejection and injury states were defined using the Molecular Microscope system. We studied the correlation between dd-cfDNA and the expression of genes, transcript sets, and classifier scores within specific disease states, and compared AMR, TCMR, and AKI to biopsies classified as normal and no injury (NRNI). RESULTS In all 604 biopsies, dd-cfDNA was elevated in AMR, TCMR, and AKI. Within AMR biopsies, dd-cfDNA correlated with AMR activity and stage. Within AKI, the correlations reflected acute parenchymal injury, including cell cycling. Within biopsies classified as MMDx Normal and archetypal No injury (NRNI), dd-cfDNA still correlated significantly with rejection- and injury-related genes. TCMR activity (eg, the TCMR Prob classifier) correlated with dd-cfDNA, but within TCMR biopsies, top gene correlations were complex and not the top TCMR-selective genes. CONCLUSIONS In kidney transplants, elevated plasma dd-cfDNA is associated with 3 distinct molecular states in the donor tissue: AMR, recent parenchymal injury (including cell cycling), and TCMR, potentially complicated by parenchymal disruption. Moreover, subtle rejection- and injury-related changes in the donor tissue can contribute to dd-cfDNA elevations in transplants considered to have no rejection or injury.
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Affiliation(s)
- Patrick T. Gauthier
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
| | - Katelynn S. Madill-Thomsen
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
| | | | | | | | - Philip F. Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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17
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Alam AH, Van Zyl J, Shakoor HI, Farsakh D, Abdelrehim AB, Maliakkal N, Jamil AK, Patel R, Felius J, McKean S, Hall SA. The impact of active cytomegalovirus infection on donor-derived cell-free DNA testing in heart transplant recipients. Clin Transplant 2024; 38:e15287. [PMID: 38477177 DOI: 10.1111/ctr.15287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/06/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Little is known about the relationship between cytomegalovirus (CMV) infections and donor-derived cell-free DNA (dd-cfDNA) in heart transplant recipients. METHODS In our study, CMV and dd-cfDNA results were prospectively collected on single-organ heart transplant recipients. If the CMV study was positive, a CMV study with dd-cfDNA was repeated 1-3 months later. The primary aim was to compare dd-cfDNA between patients with positive and negative CMV results. RESULTS Of 44 patients enrolled between August 2022 and April 2023, 12 tested positive for CMV infections, 25 were included as controls, and seven patients with a viral infection without CMV were excluded. Baseline characteristics did not differ significantly between CMV-positive and CMV-negative patients with the exception of a later median time post-transplant in the CMV-positive group (253 days vs. 120 days, p = .03). Dd-cfDNA levels were significantly higher in patients with CMV infections compared to those without (p < .001) with more patients in the CMV positive group showing dd-cfDNA results ≥.12% (75% vs. 8%, p < .001) and ≥.20% (58% vs. 8%, p = .002). Each 1 log10 copy/ml reduction in CMV viral load from visit 1 to visit 2 was associated with a.23% reduction in log10 dd-cfDNA (p = .002). CONCLUSION Our findings suggest that active CMV infections may raise dd-cfDNA levels in patients following heart transplantation. Larger studies are needed to validate these preliminary findings.
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Affiliation(s)
- Amit H Alam
- Division of Cardiology, New York University Langone Health, New York, New York, USA
| | - Johanna Van Zyl
- Texas A&M University Health Science Center College of Medicine, Dallas, Texas, USA
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Hira I Shakoor
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Dana Farsakh
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Ahmad B Abdelrehim
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Neville Maliakkal
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Aayla K Jamil
- Texas A&M University Health Science Center College of Medicine, Dallas, Texas, USA
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Raksha Patel
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Joost Felius
- Texas A&M University Health Science Center College of Medicine, Dallas, Texas, USA
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Staci McKean
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Shelley A Hall
- Texas A&M University Health Science Center College of Medicine, Dallas, Texas, USA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
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18
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Lee DH, Usmani A, Ravichandran V, Wicks T, Wu R, Wolf-Doty T, Dumitru I, Berman P, Oliveira GH, Mackie B. Relationship between blood and tissue-based rejection-related transcripts in heart transplantation. J Heart Lung Transplant 2024; 43:359-368. [PMID: 37730189 DOI: 10.1016/j.healun.2023.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 09/06/2023] [Accepted: 09/12/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND The purpose of the study is to investigate the relationship between blood and tissue-derived rejection-related transcripts from blood gene expression profiling (GEP) and molecular microscope in the setting of allograft rejection in heart transplant. METHODS All heart transplant patients from August 2021 to May 2022 with both circulating blood GEP (AlloMap) and endomyocardial biopsy with molecular microscope diagnostic system (MMDx) within 4 weeks were included (N = 173 samples). We obtained individual blood GEP-based messenger RNA transcript expression levels of the 11 target genes from CareDx. Student's t-test was performed to compare blood GEP transcript expression levels between no rejection and rejection as assessed by MMDx. A Scatter plot with Spearman correlation analysis was performed to compare the relationship between transcript expression levels from AlloMap and MMDx, with and without allograft rejection. RESULTS There were 52 samples (30.1%) with antibody-mediated rejection (ABMR) and 15 samples (8.7%) with T-cell-mediated rejection (TCMR), as assessed by MMDx. Expression of one of the blood ITGA4 (Integrin alpha 4) expression level was elevated in ABMR, compared to no ABMR (4,607.5 vs 4,217.5; p = 0.019). Most tissue rejection-associated transcript expression levels were elevated in ABMR, and tissue ROBO4 expression correlated with the blood ITGA4 expression with moderate or greater effect size in all samples (Spearman's R = 0.31; p < 0.001). There was also a positive correlation between blood ITGA4 and tissue ROBO4 expression in samples without ABMR (Spearman's R = 0.33; p < 0.001), but no correlation between blood ITGA4 and tissue ROBO4 expression in samples with ABMR (Spearman's R = 0.009; p = 0.513). CONCLUSIONS Circulating blood ITGA4 expression is elevated in antibody-mediated rejection (AMR) and correlates with myocardial expression of ROBO4. The knowledge of individual transcript expression levels in blood and in tissue may provide insights into various disease processes in heart transplant patients. Taken together, the results of our study reveal an overlap between 2 objective post-heart transplant rejection surveillance methods, identify potential novel markers for ABMR, and reveal the need for a deeper understanding of molecular mechanisms underlying allograft rejection.
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Affiliation(s)
- Dae Hyun Lee
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Heart Failure Center, Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida; Division of Cardiovascular Science, Department of Internal Medicine, Unversity of South Florida Morsani College of Medicine, Tampa, Florida.
| | - Ahsan Usmani
- Division of Cardiovascular Science, Department of Internal Medicine, Unversity of South Florida Morsani College of Medicine, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | | | - Tammi Wicks
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Heart Failure Center, Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida
| | - Robby Wu
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Heart Failure Center, Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida; Division of Cardiovascular Science, Department of Internal Medicine, Unversity of South Florida Morsani College of Medicine, Tampa, Florida
| | | | - Ioana Dumitru
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Heart Failure Center, Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida
| | - Peter Berman
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Heart Failure Center, Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida
| | - Guilherme H Oliveira
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Heart Failure Center, Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida; Division of Cardiovascular Science, Department of Internal Medicine, Unversity of South Florida Morsani College of Medicine, Tampa, Florida
| | - Benjamin Mackie
- Heart Transplant Program, Transplant Institute, Tampa General Hospital, Tampa, Florida; Heart Failure Center, Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida.
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19
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Goldberg JF, Mehta A, Bahniwal RK, Agbor-Enoh S, Shah P. A gentler approach to monitor for heart transplant rejection. Front Cardiovasc Med 2024; 11:1349376. [PMID: 38380175 PMCID: PMC10876874 DOI: 10.3389/fcvm.2024.1349376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024] Open
Abstract
Despite developments in circulating biomarker and imaging technology in the assessment of cardiovascular disease, the surveillance and diagnosis of heart transplant rejection has continued to rely on histopathologic interpretation of the endomyocardial biopsy. Increasing evidence shows the utility of molecular evaluations, such as donor-specific antibodies and donor-derived cell-free DNA, as well as advanced imaging techniques, such as cardiac magnetic resonance imaging, in the assessment of rejection, resulting in the elimination of many surveillance endomyocardial biopsies. As non-invasive technologies in heart transplant rejection continue to evolve and are incorporated into practice, they may supplant endomyocardial biopsy even when rejection is suspected, allowing for more precise and expeditious rejection therapy. This review describes the current and near-future states for the evaluation of heart transplant rejection, both in the settings of rejection surveillance and rejection diagnosis. As biomarkers of rejection continue to evolve, rejection risk prediction may allow for a more personalized approach to immunosuppression.
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Affiliation(s)
- Jason F. Goldberg
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA, United States
- Department of Children's Cardiology, Inova L.J. Murphy Children’s Hospital, Falls Church, VA, United States
| | - Aditya Mehta
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA, United States
| | | | - Sean Agbor-Enoh
- National Heart, Lung, and Blood Institute (NHLBI), NIH, Bethesda, MD, United States
| | - Palak Shah
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA, United States
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20
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Borkowski P, Singh N, Borkowska N. Advancements in Heart Transplantation: Donor-Derived Cell-Free DNA as Next-Generation Biomarker. Cureus 2024; 16:e54018. [PMID: 38476807 PMCID: PMC10930105 DOI: 10.7759/cureus.54018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/14/2024] Open
Abstract
Heart failure, particularly in its advanced stages, significantly impacts quality of life. Despite progress in Guideline-Directed Medical Therapy (GDMT) and invasive treatments, heart transplantation (HT) remains the primary option for severe cases. However, complications such as graft rejection present significant challenges that necessitate effective monitoring. Endomyocardial biopsy (EMB) is the gold standard for detecting rejection, but its invasive nature, associated risks, and healthcare costs have shifted interest in non-invasive techniques. Donor-derived cell-free DNA (dd-cfDNA) has gained attention as a promising non-invasive biomarker for monitoring graft rejection. Compared to EMB, dd-cfDNA detects graft rejection early and enables clinicians to adjust immunosuppression promptly. Despite its advantages, dd-cfDNA testing faces challenges, such as the need for specialized technology and potential inaccuracies due to other clinical conditions. Additionally, dd-cfDNA cannot yet differentiate between types of graft rejection, and its effectiveness in chronic rejection remains unclear. Research is ongoing to set precise standards for dd-cfDNA levels, which would enhance its diagnostic accuracy and help in clinical decisions. The article also points to the future of HT monitoring, which may involve combining dd-cfDNA with other biomarkers and integrating artificial intelligence to improve diagnostic capabilities and personalize patient care. Furthermore, it emphasizes both global and racial inequalities in dd-cfDNA testing and the ethical issues related to its use in transplant medicine.
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Affiliation(s)
- Pawel Borkowski
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Nikita Singh
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Natalia Borkowska
- Pediatrics, SPZOZ (Samodzielny Publiczny Zakład Opieki Zdrowotnej) Krotoszyn, Krotoszyn, POL
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21
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Martini L, Mandoli GE, Pastore MC, Pagliaro A, Bernazzali S, Maccherini M, Henein M, Cameli M. Heart transplantation and biomarkers: a review about their usefulness in clinical practice. Front Cardiovasc Med 2024; 11:1336011. [PMID: 38327491 PMCID: PMC10847311 DOI: 10.3389/fcvm.2024.1336011] [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: 11/09/2023] [Accepted: 01/12/2024] [Indexed: 02/09/2024] Open
Abstract
Advanced heart failure (AdvHF) can only be treated definitively by heart transplantation (HTx), yet problems such right ventricle dysfunction (RVD), rejection, cardiac allograft vasculopathy (CAV), and primary graft dysfunction (PGD) are linked to a poor prognosis. As a result, numerous biomarkers have been investigated in an effort to identify and prevent certain diseases sooner. We looked at both established biomarkers, such as NT-proBNP, hs-troponins, and pro-inflammatory cytokines, and newer ones, such as extracellular vesicles (EVs), donor specific antibodies (DSA), gene expression profile (GEP), donor-derived cell free DNA (dd-cfDNA), microRNA (miRNA), and soluble suppression of tumorigenicity 2 (sST2). These biomarkers are typically linked to complications from HTX. We also highlight the relationships between each biomarker and one or more problems, as well as their applicability in routine clinical practice.
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Affiliation(s)
- L. Martini
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - G. E. Mandoli
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - M. C. Pastore
- Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - A. Pagliaro
- Cardio-Thoracic-Vascular Department, Siena University Hospital, Siena, Italy
| | - S. Bernazzali
- Cardio-Thoracic-Vascular Department, Siena University Hospital, Siena, Italy
| | - M. Maccherini
- Cardio-Thoracic-Vascular Department, Siena University Hospital, Siena, Italy
| | - M. Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - M. Cameli
- Department of Medical Biotechnology, University of Siena, Siena, Italy
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22
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Srivastava PK, Kittleson MM. Modern advances in heart transplantation. Prog Cardiovasc Dis 2024; 82:147-156. [PMID: 38244826 DOI: 10.1016/j.pcad.2024.01.012] [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: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
Heart transplantation (HTx) is the only definitive therapy for patients with end stage heart disease. With the increasing global prevalence of heart failure, the demand for HTx has continued to grow and outpace supply. In this paper, we will review advances in the field of HTx along the clinical journey of a HTx recipient. Starting with the sensitized patient, we discuss current methods to define sensitization, and assays to help identify clinically relevant anti-HLA antibodies. Desensitization strategies targeting all levels of the adaptive immune system are discussed with emphasis on novel techniques such as anti-CD 38 blockade and use of the Immunoglobulin G-Degrading Enzyme of Streptococcus Pyogenes. We next discuss donor procurement and the resurgence of donation after circulatory death as a viable strategy to significantly and safely increase the donor pool. Post-transplant, we evaluate non-invasive surveillance techniques including gene expression profiling and donor-derived cell-free DNA. Last, we discuss the ground-breaking developments in the field of xenotransplantation.
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Affiliation(s)
- Pratyaksh K Srivastava
- Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, CA, United States of America
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute at Cedars-Sinai, Los Angeles, CA, United States of America.
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23
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Kuczaj A, Przybyłowski P, Hrapkowicz T. Torque Teno Virus (TTV)-A Potential Marker of Immunocompetence in Solid Organ Recipients. Viruses 2023; 16:17. [PMID: 38275952 PMCID: PMC10818937 DOI: 10.3390/v16010017] [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] [Revised: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024] Open
Abstract
Torque Teno Virus (TTV), first discovered in 1997, is a non-pathogenic, highly prevalent virus with a notable presence in the human virome. TTV has garnered attention as a potential indicator of immunocompetence in recipients of solid organ transplants. In this review, we discuss the role of TTV as a potential marker for immunosuppression optimization, prediction of graft rejection, and as an indicator of opportunistic infections. We discuss TTV's behavior over the course of time after transplantation, TTV's implications in different immunosuppressive regimens, and potential utility in vaccinations. The review synthetizes findings from various studies depicting its potential clinical utility for future personalized patient care.
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Affiliation(s)
- Agnieszka Kuczaj
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (P.P.); (T.H.)
- Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
| | - Piotr Przybyłowski
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (P.P.); (T.H.)
- Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
| | - Tomasz Hrapkowicz
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland; (P.P.); (T.H.)
- Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
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24
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Xie X, Wu Q. Basic situation and trend analysis in heart transplantation research funded by the National Natural Science Foundation of China. Clin Transplant 2023; 37:e15108. [PMID: 37638397 DOI: 10.1111/ctr.15108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION This study analyzes heart transplantation funding provided by the National Natural Science Foundation of China (NSFC) between 1986 and 2022. The findings offer an objective and scientific reference for heart transplantation research. METHODS CiteSpace visualization was used to present keywords in heart transplantation research. RESULTS From 1986 to 2022, the NFSC disbursed ¥117.68 million to fund 259 projects related to heart transplantation. Hubei, Shanghai, Beijing, Guangdong, and Heilongjiang received the most funding. General and youth science fund projects accounted for 58.69% and 30.50%, respectively. The main discipline category was organ transplantation and transplantation immunity, accounting for 40.93%. Research hotspots included "immune tolerance," "rejection reaction," "t cell" "dendritic cell," "stem cell," and "transplantation tolerance." Research foci were "rejection reaction," "heart failure," "immune tolerance," "heart transplantation," "stem cell," "suppressor cell," "dendritic cell," "dilated cardiomyopathy," and "t cell." In the past 5 years, the research frontier has targeted "transplantation tolerance," "ischemia-reperfusion injury," and "heart transplantation." CONCLUSION Continuous NSFC funding for heart transplantation research has promoted the development of disciplines and cultivation of talent. Novel technologies (e.g., artificial hearts and donor maintenance) have generated new requirements for heart transplantation research.
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Affiliation(s)
- Xianyu Xie
- Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| | - Qinde Wu
- Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
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25
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Alam A, van Zyl JS, Afzal A, Felius J, Hall SA, Meyer DM, Carey SA. Early elevated donor-derived cell-free DNA levels in heart transplant recipients following precision-controlled cardiac transport system or ice-cooled organ transport. Clin Transplant 2023; 37:e15151. [PMID: 37922318 DOI: 10.1111/ctr.15151] [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: 08/07/2023] [Revised: 09/11/2023] [Accepted: 09/21/2023] [Indexed: 11/05/2023]
Abstract
BACKGROUND Recent innovations in temperature-controlled cardiac transportation allow for static hypothermic preservation of transplant organs during transportation. We assessed differences in donor-derived cell-free DNA (dd-cfDNA) using the SherpaPak cardiac transport system (SCTS) and traditional ice transportation. METHODS Single-organ heart transplant recipients between January 2020 and January 2022 were included if they had dd-cfDNA measures ≤6 weeks post-transplant along with the baseline biopsy at 6 weeks as part of the surveillance protocol and no biopsy-confirmed rejection ≤90 days. Elevated dd-cfDNA ≥.20% were compared between groups using logistic regression including a subject effect. RESULTS Of 65 hearts transplanted, 30 were transported with SCTS and 35 on ice. Recipient characteristics were similar between groups. Donors in the SCTS group were older (34 vs. 40 years, p = .04) with a longer total ischemic time (171 vs. 212 min, p = .002). Recipients in the SCTS group had a greater risk of elevated dd-cfDNA unadjusted and adjusted for donor age, and prolonged ischemic times > 3.5 h (Unadjusted odds ratio: 4.9, 95%-CI: 1.08-22.5, p = .039 and Adjusted odds ratio: 5.5, 95%-CI: 1.03-29.6, p = .046). Primary graft dysfunction rates and 1-year mortality were comparable between groups. CONCLUSION Elevated dd-cfDNA in patients procured with SCTS may indicate that graft injury was not negated relative to ice transport. However, there were no clinical differences noted in short or long-term outcomes including mortality despite a longer ischemic time in the SCTS group.
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Affiliation(s)
- Amit Alam
- Division of Cardiology, New York University Grossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Johanna S van Zyl
- Texas A&M University Health Science Center College of Medicine, Dallas, Texas, USA
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Aasim Afzal
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
- The Heart Hospital Baylor Plano, Baylor Scott & White Health, Plano, Texas, USA
| | - Joost Felius
- Texas A&M University Health Science Center College of Medicine, Dallas, Texas, USA
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
| | - Shelley A Hall
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Dan M Meyer
- Baylor Scott & White Research Institute, Baylor Scott & White Health, Dallas, Texas, USA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
| | - Sandra A Carey
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, USA
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26
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Mehlman Y, Valledor AF, Moeller C, Rubinstein G, Lotan D, Rahman S, Oh KT, Bae D, DeFilippis EM, Lin EF, Lee SH, Raikhelkar JK, Fried J, Theodoropoulos K, Colombo PC, Yuzefpolskaya M, Latif F, Clerkin KJ, Sayer GT, Uriel N. The utilization of molecular microscope in management of heart transplant recipients in the era of noninvasive monitoring. Clin Transplant 2023; 37:e15131. [PMID: 37897211 DOI: 10.1111/ctr.15131] [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: 06/01/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION Monitoring for graft rejection is a fundamental tenet of post-transplant follow-up. In heart transplantation (HT) in particular, rejection has been traditionally assessed with endomyocardial biopsy (EMB). EMB has potential complications and noted limitations, including interobserver variability in interpretation. Additional tests, such as basic cardiac biomarkers, cardiac imaging, gene expression profiling (GEP) scores, donor-derived cell-free DNA (dd-cfDNA) and the novel molecular microscope diagnostic system (MMDx) have become critical tools in rejection surveillance beyond standard EMB. METHODS This paper describes an illustrative case followed by a review of MMDx within the context of other noninvasive screening modalities for rejection. CONCLUSIONS We suggest MMDx be used to assist with early detection of rejection in cases of discordance between EMB and other noninvasive studies.
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Affiliation(s)
- Yonatan Mehlman
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Andrea Fernendez Valledor
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Cathrine Moeller
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Gal Rubinstein
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Dor Lotan
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Salwa Rahman
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Kyung T Oh
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - David Bae
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Edward F Lin
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Sun Hi Lee
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Jayant K Raikhelkar
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Justin Fried
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Kleanthis Theodoropoulos
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Farhana Latif
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Kevin J Clerkin
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Gabriel T Sayer
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York, New York, USA
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27
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Alam A, Van Zyl J, McKean S, Abdelrehim A, Patel R, Milligan G, Hall S. Rejection! Or is it? Correlation among molecular microscope diagnostic system, histopathology and clinical judgement following heart transplantation. Transpl Immunol 2023; 81:101924. [PMID: 37648034 DOI: 10.1016/j.trim.2023.101924] [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: 06/13/2023] [Revised: 08/17/2023] [Accepted: 08/27/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Little is known about clinical decision making among discordant findings concerning for rejection with endomyocardial biopsy (EMBx) and Molecular Microscope Diagnostic System (MMDx) in patients following heart transplantation. METHODS Two hundred and twenty-eight corresponding EMBx and MMDx specimens from 135 adult heart transplant patients were retrospectively reviewed. Rejection was classified as t-cell mediated rejection ≥2R and/or antibody mediated rejection ≥1. Clinical decision making among concordant and discordant cases of EMBx and MMDx results were reviewed. RESULTS Patient characteristics were comparable between concordant and discordant patient groups (median age 60 yrs., 76% male, and 71% White). A total of 167/228 specimens (73%) were concordant for no rejection with 98% agreement in clinical decision making and 25/228 (11%) concordant for rejection with 64% agreement in clinical decision making. Among the 36/228 (16%) discordant samples, clinical decision-making agreed on treatment for rejection in five of the MMDx samples and three of the EMBx samples. CONCLUSIONS MMDx can be an additional tool to diagnose rejection not detected by the traditional EMBx and influence clinical decision making in guiding appropriate treatment. Ongoing investigation into the clinical utility of MMDx is warranted to determine the significance of discordant findings among diagnostic modalities when assessing for rejection.
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Affiliation(s)
- Amit Alam
- New York University, New York, NY, USA.
| | | | - Staci McKean
- Baylor University Medical Center, Dallas, TX, USA
| | | | - Raksha Patel
- Baylor University Medical Center, Dallas, TX, USA
| | | | - Shelley Hall
- Baylor University Medical Center, Dallas, TX, USA
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Crisci G, Bobbio E, Gentile P, Bromage DI, Bollano E, Ferone E, Israr MZ, Heaney LM, Polte CL, Cannatà A, Salzano A. Biomarkers in Acute Myocarditis and Chronic Inflammatory Cardiomyopathy: An Updated Review of the Literature. J Clin Med 2023; 12:7214. [PMID: 38068265 PMCID: PMC10706911 DOI: 10.3390/jcm12237214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/10/2023] [Accepted: 11/17/2023] [Indexed: 02/15/2024] Open
Abstract
Myocarditis is a disease caused by cardiac inflammation that can progress to dilated cardiomyopathy, heart failure, and eventually death. Several etiologies, including autoimmune, drug-induced, and infectious, lead to inflammation, which causes damage to the myocardium, followed by remodeling and fibrosis. Although there has been an increasing understanding of pathophysiology, early and accurate diagnosis, and effective treatment remain challenging due to the high heterogeneity. As a result, many patients have poor prognosis, with those surviving at risk of long-term sequelae. Current diagnostic methods, including imaging and endomyocardial biopsy, are, at times, expensive, invasive, and not always performed early enough to affect disease progression. Therefore, the identification of accurate, cost-effective, and prognostically informative biomarkers is critical for screening and treatment. The review then focuses on the biomarkers currently associated with these conditions, which have been extensively studied via blood tests and imaging techniques. The information within this review was retrieved through extensive literature research conducted on major publicly accessible databases and has been collated and revised by an international panel of experts. The biomarkers discussed in the article have shown great promise in clinical research studies and provide clinicians with essential tools for early diagnosis and improved outcomes.
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Affiliation(s)
- Giulia Crisci
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy;
- Italian Clinical Outcome Research and Reporting Program (I-CORRP), 80131 Naples, Italy
| | - Emanuele Bobbio
- Department of Cardiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden; (E.B.); (E.B.)
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, 41390 Gothenburg, Sweden;
| | - Piero Gentile
- De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy;
| | - Daniel I. Bromage
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK; (D.I.B.); (E.F.)
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London SE5 8AF, UK
| | - Entela Bollano
- Department of Cardiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden; (E.B.); (E.B.)
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, 41390 Gothenburg, Sweden;
| | - Emma Ferone
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK; (D.I.B.); (E.F.)
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London SE5 8AF, UK
| | - Muhammad Zubair Israr
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Groby Road, Leicester LE3 9QP, UK;
| | - Liam M. Heaney
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK;
| | - Christian L. Polte
- Institute of Medicine, The Sahlgrenska Academy at the University of Gothenburg, 41390 Gothenburg, Sweden;
- Department of Clinical Physiology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
| | - Antonio Cannatà
- Department of Cardiology, King’s College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK; (D.I.B.); (E.F.)
- Department of Cardiovascular Sciences, Faculty of Life Sciences & Medicine, King’s College London, London SE5 8AF, UK
| | - Andrea Salzano
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Groby Road, Leicester LE3 9QP, UK;
- Cardiology Unit, AORN A Cardarelli, 80131 Naples, Italy
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Battle R, Pritchard D, Peacock S, Hastie C, Worthington J, Jordan S, McCaughlan JA, Barnardo M, Cope R, Collins C, Diaz-Burlinson N, Rosser C, Foster L, Kallon D, Shaw O, Briggs D, Turner D, Anand A, Akbarzad-Yousefi A, Sage D. BSHI and BTS UK guideline on the detection of alloantibodies in solid organ (and islet) transplantation. Int J Immunogenet 2023; 50 Suppl 2:3-63. [PMID: 37919251 DOI: 10.1111/iji.12641] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Abstract
Solid organ transplantation represents the best (and in many cases only) treatment option for patients with end-stage organ failure. The effectiveness and functioning life of these transplants has improved each decade due to surgical and clinical advances, and accurate histocompatibility assessment. Patient exposure to alloantigen from another individual is a common occurrence and takes place through pregnancies, blood transfusions or previous transplantation. Such exposure to alloantigen's can lead to the formation of circulating alloreactive antibodies which can be deleterious to solid organ transplant outcome. The purpose of these guidelines is to update to the previous BSHI/BTS guidelines 2016 on the relevance, assessment, and management of alloantibodies within solid organ transplantation.
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Affiliation(s)
- Richard Battle
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | | | - Sarah Peacock
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - Sue Jordan
- National Blood Service Tooting, London, UK
| | | | - Martin Barnardo
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rebecca Cope
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | | | - Luke Foster
- Birmingham Blood Donor Centre, Birmingham, UK
| | | | - Olivia Shaw
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - David Turner
- Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Arthi Anand
- Imperial College Healthcare NHS Trust, London, UK
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Böhmer J, Wasslavik C, Andersson D, Ståhlberg A, Jonsson M, Wåhlander H, Karason K, Sunnegårdh J, Nilsson S, Asp J, Dellgren G, Ricksten A. Absolute Quantification of Donor-Derived Cell-Free DNA in Pediatric and Adult Patients After Heart Transplantation: A Prospective Study. Transpl Int 2023; 36:11260. [PMID: 37965628 PMCID: PMC10641041 DOI: 10.3389/ti.2023.11260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 10/18/2023] [Indexed: 11/16/2023]
Abstract
In this prospective study we investigated a cohort after heart transplantation with a novel PCR-based approach with focus on treated rejection. Blood samples were collected coincidentally to biopsies, and both absolute levels of dd-cfDNA and donor fraction were reported using digital PCR. 52 patients (11 children and 41 adults) were enrolled (NCT03477383, clinicaltrials.gov), and 557 plasma samples were analyzed. 13 treated rejection episodes >14 days after transplantation were observed in 7 patients. Donor fraction showed a median of 0.08% in the cohort and was significantly elevated during rejection (median 0.19%, p < 0.0001), using a cut-off of 0.1%, the sensitivity/specificity were 92%/56% (AUC ROC-curve: 0.78). Absolute levels of dd-cfDNA showed a median of 8.8 copies/mL and were significantly elevated during rejection (median 23, p = 0.0001). Using a cut-off of 7.5 copies/mL, the sensitivity/specificity were 92%/43% for donor fraction (AUC ROC-curve: 0.75). The results support the feasibility of this approach in analyzing dd-cfDNA after heart transplantation. The obtained values are well aligned with results from other trials. The possibility to quantify absolute levels adds important value to the differentiation between ongoing graft damage and quiescent situations.
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Affiliation(s)
- Jens Böhmer
- Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Daniel Andersson
- Sahlgrenska Cancer Center, University of Gothenburg, Gothenburg, Sweden
| | - Anders Ståhlberg
- Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Cancer Center, University of Gothenburg, Gothenburg, Sweden
- The Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Marianne Jonsson
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Håkan Wåhlander
- Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristjan Karason
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan Sunnegårdh
- Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Staffan Nilsson
- Laboratory Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Julia Asp
- Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Dellgren
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anne Ricksten
- Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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31
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Mantios E, Filiopoulos V, Constantoulakis P, Liapis G, Vittoraki A, Casas S, Marinaki S, Boletis JN. Assessment of Donor Derived Cell Free DNA (dd-cfDNA) at Surveillance and at Clinical Suspicion of Acute Rejection in Renal Transplantation. Transpl Int 2023; 36:11507. [PMID: 37901296 PMCID: PMC10603235 DOI: 10.3389/ti.2023.11507] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023]
Abstract
In our prospective, unicenter cohort study, we collected blood samples from 30 newly kidney transplanted patients, at month 1, 2, 3, and 5 for dd-cfDNA analysis, along with creatinine/eGFR and DSA monitoring, and from 32 patients who underwent an indication biopsy and whose dd-cfDNA levels were measured at the time of biopsy and 1 month afterwards. Fourteen of 32 (43.8%) patients in the biopsy group were diagnosed with TCMR and 5 of 32 (15.6%) with ABMR. Dd-cfDNA proved to be better than creatinine in diagnosing rejection from non-rejection in patients who were biopsied. When a dd-cfDNA threshold of 0.5% was chosen, sensitivity was 73.7% and specificity was 92.3% (AUC: 0.804, 0.646-0.961). In rejection patients, levels of dd-cfDNA prior to biopsy (0.94%, 0.3-2.0) decreased substantially after initiation of treatment with median returning to baseline already at 1 month (0.33%, 0.21-0.51, p = 0.0036). In the surveillance group, high levels of dd-cfDNA (>0.5%) from second month post-transplantation were correlated with non-increasing eGFR 1 year post-transplantation. The study used AlloSeq kit for kidney transplant surveillance for first time and confirmed dd-cfDNA's ability to detect rejection and monitor treatment, as well as to predict worse long-term outcomes regarding eGFR.
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Affiliation(s)
- Evangelos Mantios
- Department of Nephrology and Kidney Transplantation, School of Medicine, General Hospital of Athens Laiko, National and Kapodistrian University of Athens, Athens, Greece
| | - Vassilis Filiopoulos
- Department of Nephrology and Kidney Transplantation, School of Medicine, General Hospital of Athens Laiko, National and Kapodistrian University of Athens, Athens, Greece
| | | | - George Liapis
- Pathology Department, School of Medicine, General Hospital of Athens Laiko, National and Kapodistrian University of Athens, Athens, Greece
| | - Angeliki Vittoraki
- Immunology Department, National Tissue Typing Center, General Hospital of Athens “G. Gennimatas”, Athens, Greece
| | | | - Smaragdi Marinaki
- Department of Nephrology and Kidney Transplantation, School of Medicine, General Hospital of Athens Laiko, National and Kapodistrian University of Athens, Athens, Greece
| | - John N Boletis
- Department of Nephrology and Kidney Transplantation, School of Medicine, General Hospital of Athens Laiko, National and Kapodistrian University of Athens, Athens, Greece
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González-López E, Ocejo-Vinyals JG, Renuncio-García M, Roa-Bautista A, San Segundo Arribas D, Escagedo C, García-Saiz MDM, Valero R, García-Berbel P, Ruíz San Millán JC, Rodrigo E. Donor-Derived Cell-Free DNA at 1 Month after Kidney Transplantation Relates to HLA Class II Eplet Mismatch Load. Biomedicines 2023; 11:2741. [PMID: 37893114 PMCID: PMC10604614 DOI: 10.3390/biomedicines11102741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/03/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
Kidney transplantation is the preferred therapeutic option for end-stage renal disease; however, the alloimmune response is still the leading cause of renal allograft failure. To better identify immunologic disparities in order to evaluate HLA compatibility between the donor and the recipient, the concept of eplet load has arisen. Regular kidney function monitoring is essential for the accurate and timely diagnosis of allograft rejection and the appropriate treatment. Donor-derived cell-free DNA (dd-cfDNA) has been proposed as a potential biomarker of acute rejection and graft failure in kidney transplantation. The proportion of plasma dd-cfDNA was determined in forty-two kidney patients at 1 month after transplantation. A total of eleven (26.2%) patients had a dd-cfDNA proportion of ≥1.0%. The only pretransplant variable related to dd-cfDNA > 1.0% was the HLA class II eplet mismatch load, mainly the HLA-DQB1 eplet mismatch load. Furthermore, dd-cfDNA was able to discriminate the patients with antibody-mediated rejection (AbMR) (AUC 87.3%), acute rejection (AUC 78.2%), and troubled graft (AUC 81.4%). Increased dd-cfDNA levels were associated with kidney allograft deterioration, particularly rejection, as well as a greater HLA class II eplet mismatch load. Consequently, combining dd-cfDNA determination and HLA eplet mismatch load calculation should improve the assessment of the risk of short- and long-term allograft damage.
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Affiliation(s)
- Elena González-López
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain; (E.G.-L.); (M.R.-G.); (A.R.-B.); (D.S.S.A.)
| | - Javier Gonzalo Ocejo-Vinyals
- Immunology Department, Infectious Diseases and Clinical Microbiology Group, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain;
| | - Mónica Renuncio-García
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain; (E.G.-L.); (M.R.-G.); (A.R.-B.); (D.S.S.A.)
| | - Adriel Roa-Bautista
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain; (E.G.-L.); (M.R.-G.); (A.R.-B.); (D.S.S.A.)
| | - David San Segundo Arribas
- Immunology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain; (E.G.-L.); (M.R.-G.); (A.R.-B.); (D.S.S.A.)
| | - Clara Escagedo
- Nephrology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain; (C.E.); (R.V.); (J.C.R.S.M.)
| | - María del Mar García-Saiz
- Clinical Pharmacology Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain;
| | - Rosalía Valero
- Nephrology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain; (C.E.); (R.V.); (J.C.R.S.M.)
| | - Pilar García-Berbel
- Pathological Anatomy Department, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain;
| | - Juan Carlos Ruíz San Millán
- Nephrology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain; (C.E.); (R.V.); (J.C.R.S.M.)
| | - Emilio Rodrigo
- Nephrology Department, Immunopathology Group, Marqués de Valdecilla University Hospital-IDIVAL, University of Cantabria, 39008 Santander, Spain; (C.E.); (R.V.); (J.C.R.S.M.)
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Baran DA. Anything But a Biopsy: The Quest for Noninvasive Alternatives in Heart Transplantation. Transplantation 2023; 107:1875-1876. [PMID: 37143200 DOI: 10.1097/tp.0000000000004623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Affiliation(s)
- David A Baran
- Department of Cardiology, Advanced Heart Failure, Transplant and MCS, Cleveland Clinic Heart, Vascular and Thoracic Institute, Weston, FL
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34
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Berezina TA, Berezin AE. Cell-free DNA as a plausible biomarker of chronic kidney disease. Epigenomics 2023; 15:879-890. [PMID: 37791402 DOI: 10.2217/epi-2023-0255] [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] [Indexed: 10/05/2023] Open
Abstract
Circulating cell-free DNA (cf-DNA) is released from dead and/or apoptotic leukocytes and due to neutrophil extracellular traps contributing to an inflammatory response. Previous clinical studies have reported that the peak concentrations and dynamic changes of cf-DNA may be used as a noninvasive biomarker of worsening kidney function as well as a guide to the management of kidney allograft rejection. We hypothesized that the pattern and dynamic changes of cf-DNA might be a plausible predictive biomarker for patients at risk of chronic kidney disease (CKD), including individuals with type 2 diabetes mellitus, heart failure, cardiovascular disease and established CKD. Along with it, pre- and posthemodialysis levels of serum cf-DNA appear to be a independent predictor for all-cause mortality in patients with end-stage kidney disease.
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Affiliation(s)
- Tetiana A Berezina
- VitaCenter, Department of Internal Medicine and Nephrology, Zaporozhye, 69000, Ukraine
| | - Alexander E Berezin
- Paracelsus Medical University, Department of Internal Medicine II, Division of Cardiology, Salzburg, 5020, Austria
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35
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Teszak T, Bödör C, Hegyi L, Levay L, Nagy B, Fintha A, Merkely B, Sax B. Local laboratory-run donor-derived cell-free DNA assay for rejection surveillance in heart transplantation-first six months of clinical experience. Clin Transplant 2023; 37:e15078. [PMID: 37489087 DOI: 10.1111/ctr.15078] [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: 05/17/2023] [Revised: 07/02/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Donor-derived cell-free DNA (dd-cfDNA) is a blood biomarker detecting graft injury with high negative predictive value. While non-invasive strategies for heart transplant (HTx) rejection surveillance are widely adopted in the United States with centralized testing, data on the feasibility of dd-cfDNA assay at the local level are lacking. Here, we report the first 6 months of experience with a local laboratory-run dd-cfDNA assay in the routine clinical surveillance setting. METHODS Twenty-six HTx patients with stable graft function were transitioned from endomyocardial biopsy-based (EMB) to dd-cfDNA-led rejection surveillance using a commercially available next-generation sequencing-based assay. RESULTS In the 90 samples analyzed, dd-cfDNA fraction remained continuously low in most patients, thus 88% of surveillance EMBs could be safely avoided. In the case of ≥.25% dd-cfDNA, EMB was performed. There was no missed rejection. CONCLUSION Our data show the feasibility to analyze dd-cfDNA at the local level and successful implementation of this non-invasive surveillance method into clinical practice, thus considerably reducing the frequency of invasive surveillance EMBs.
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Affiliation(s)
- Timea Teszak
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Csaba Bödör
- Molecular Diagnostics Division, Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
- HCEMM-SE Molecular Oncohematology Research Group, Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Lajos Hegyi
- Molecular Diagnostics Division, Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
- HCEMM-SE Molecular Oncohematology Research Group, Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Luca Levay
- Molecular Diagnostics Division, Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
- HCEMM-SE Molecular Oncohematology Research Group, Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Beata Nagy
- Molecular Diagnostics Division, Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Attila Fintha
- Molecular Diagnostics Division, Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Balazs Sax
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
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36
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Goldberg JF, Truby LK, Agbor-Enoh S, Jackson AM, deFilippi CR, Khush KK, Shah P. Selection and Interpretation of Molecular Diagnostics in Heart Transplantation. Circulation 2023; 148:679-694. [PMID: 37603604 PMCID: PMC10449361 DOI: 10.1161/circulationaha.123.062847] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
The number of heart transplants performed annually in the United States and worldwide continues to increase, but there has been little change in graft longevity and patient survival over the past 2 decades. The reference standard for diagnosis of acute cellular and antibody-mediated rejection includes histologic and immunofluorescence evaluation of endomyocardial biopsy samples, despite invasiveness and high interrater variability for grading histologic rejection. Circulating biomarkers and molecular diagnostics have shown substantial predictive value in rejection monitoring, and emerging data support their use in diagnosing other posttransplant complications. The use of genomic (cell-free DNA), transcriptomic (mRNA and microRNA profiling), and proteomic (protein expression quantitation) methodologies in diagnosis of these posttransplant outcomes has been evaluated with varying levels of evidence. In parallel, growing knowledge about the genetically mediated immune response leading to rejection (immunogenetics) has enhanced understanding of antibody-mediated rejection, associated graft dysfunction, and death. Antibodies to donor human leukocyte antigens and the technology available to evaluate these antibodies continues to evolve. This review aims to provide an overview of biomarker and immunologic tests used to diagnose posttransplant complications. This includes a discussion of pediatric heart transplantation and the disparate rates of rejection and death experienced by Black patients receiving a heart transplant. This review describes diagnostic modalities that are available and used after transplant and the landscape of future investigations needed to enhance patient outcomes after heart transplantation.
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Affiliation(s)
- Jason F Goldberg
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA (J.F.G., C.R.d., P.S.)
- Department of Pediatrics, Inova L.J. Murphy Children's Hospital, Falls Church, VA (J.F.G.)
| | - Lauren K Truby
- Department of Medicine, University of Texas Southwestern, Dallas (L.K.T.)
| | - Sean Agbor-Enoh
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (S.A.-E.)
- Applied Precision Genomics, National Heart, Lung and Blood Institute, Bethesda, MD (S.A.-E.)
| | - Annette M Jackson
- Department of Surgery, Duke University School of Medicine, Durham, NC (A.M.J.)
| | - Christopher R deFilippi
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA (J.F.G., C.R.d., P.S.)
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, CA (K.K.K.)
| | - Palak Shah
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, VA (J.F.G., C.R.d., P.S.)
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Raszeja-Wyszomirska J, Macech M, Kolanowska M, Krawczyk M, Nazarewski S, Wójcicka A, Małyszko J. Free-Circulating Nucleic Acids as Biomarkers in Patients After Solid Organ Transplantation. Ann Transplant 2023; 28:e939750. [PMID: 37580899 PMCID: PMC10439677 DOI: 10.12659/aot.939750] [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: 02/07/2023] [Accepted: 05/17/2023] [Indexed: 08/16/2023] Open
Abstract
A number types of extracellular DNA (eg, cell-free, cfDNA) circulate in human blood, including mitochondrial, transcriptome, and regulatory DNA, usually at low concentrations. Larger amounts of cfDNA appear in any inflammatory condition, including organ damage due to a variety of reasons. The role of cfDNA in solid organ transplantation is discussed in this review as a valuable additional tool in the standard of care of transplant patients. Post-transplant monitoring requires the use of high-quality biomarkers for early detection of graft damage or rejection to be able to apply early therapeutic intervention. CfDNA complements the traditional monitoring strategies, being a risk stratification tool and an important prognostic marker. However, improving the sensitivity and specificity of cfDNA detection is necessary to facilitate personalized patient management, warranting further research in terms of measurement, test standardization, and storage, processing, and shipping. A diagnostic test (Allosure, CareDx, Inc., Brisbane, CA) for kidney, heart and lung transplant patients is now commercially available, and validation for other organs (eg, liver) is pending. To date, donor-derived cfDNA in combination with other biomarkers appears to be a promising tool in graft rejection as it is minimally invasive, time-sensitive, and cost-effective. However, improvement of sensitivity and specificity is required to facilitate personalized patient management. Whether it could be an alternate to graft biopsy remains unclear.
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Affiliation(s)
- Joanna Raszeja-Wyszomirska
- Department of Hepatology, Transplantology, and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Michał Macech
- Department of General, Vascular, and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | | | - Marek Krawczyk
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Sławomir Nazarewski
- Department of General, Vascular, and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | | | - Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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Alam A, Wilcox JE, Hall SA. The Traditional Endomyocardial Biopsy: Opportunities to Rethink Its Role as the Gold Standard. J Card Fail 2023; 29:1225-1227. [PMID: 34242781 DOI: 10.1016/j.cardfail.2021.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Amit Alam
- Baylor University Medical Center, Dallas, Texas; Texas A&M University College of Medicine, Bryan, Texas.
| | - Jane E Wilcox
- Northwestern University Medical Center, Chicago, Illinois
| | - Shelley A Hall
- Baylor University Medical Center, Dallas, Texas; Texas A&M University College of Medicine, Bryan, Texas
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39
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Cusi V, Vaida F, Wettersten N, Rodgers N, Tada Y, Gerding B, Greenberg B, Urey MA, Adler E, Kim PJ. Benefit versus Risk of Endomyocardial Biopsy for Heart Transplant Patients in the Contemporary Era. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.19.23290196. [PMID: 37293037 PMCID: PMC10246074 DOI: 10.1101/2023.05.19.23290196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background The reference standard of detecting acute rejection (AR) in adult heart transplant (HTx) patients is an endomyocardial biopsy (EMB). The majority of EMBs are performed in asymptomatic patients. However, the benefit of diagnosing and treating AR compared to the risk of EMB complications has not been compared in the contemporary era (2010-current). Methods The authors retrospectively analyzed 2,769 EMB obtained in 326 consecutive HTx patients between August 2019 and August 2022. Variables included surveillance versus for cause indication, recipient and donor characteristics, EMB procedural data and pathologic grades, treatment for AR, and clinical outcomes. Results The overall EMB complication rate was 1.6%. EMBs performed within 1 month after HTx compared to after 1 month from HTx showed significantly increased complications (OR = 12.74, p < 0.001). The treated AR rate was 14.2% in the for cause EMBs and 1.2% in the surveillance EMBs. We found the benefit/risk ratio was significantly lower in the surveillance compared to the for cause EMB group (OR = 0.05, p < 0.001). We also found the benefit to be lower than risk in surveillance EMBs. Conclusions The yield of surveillance EMBs has declined, while for cause EMBs continued to demonstrate a high benefit/risk ratio. The risk of EMB complications was highest within 1 month after HTx. Surveillance EMB protocols in the contemporary era may need to be re-evaluated.
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Cox DRA, McClure T, Zhang F, Wong BKL, Testro A, Goh SK, Muralidharan V, Dobrovic A. Graft-Derived Cell-Free DNA Quantification following Liver Transplantation Using Tissue-Specific DNA Methylation and Donor-Specific Genotyping Techniques: An Orthogonal Comparison Study. EPIGENOMES 2023; 7:11. [PMID: 37367181 DOI: 10.3390/epigenomes7020011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/07/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023] Open
Abstract
Background: Graft-derived cell-free DNA (gdcfDNA) analysis has shown promise as a non-invasive tool for monitoring organ health following solid organ transplantation. A number of gdcfDNA analysis techniques have been described; however, the majority rely on sequencing or prior genotyping to detect donor-recipient mis-matched genetic polymorphisms. Differentially methylated regions of DNA can be used to identify the tissue-of-origin of cell-free DNA (cfDNA) fragments. In this study, we aimed to directly compare the performance of gdcfDNA monitoring using graft-specific DNA methylation analysis and donor-recipient genotyping techniques in a pilot cohort of clinical samples from patients post-liver transplantation. Results: 7 patients were recruited prior to LT, 3 developed early, biopsy-proven TCMR in the first 6 weeks post-LT. gdcfDNA was successfully quantified in all samples using both approaches. There was a high level of technical correlation between results using the two techniques (Spearman testing, rs = 0.87, p < 0.0001). gdcfDNA levels quantified using the genotyping approach were significantly greater across all timepoints in comparison to the tissue-specific DNA methylation-based approach: e.g., day 1 post-LT median 31,350 copies/mL (IQR 6731-64,058) vs. 4133 copies/mL (IQR 1100-8422), respectively. Qualitative trends in gdcfDNA levels for each patient were concordant between the two assays. Acute TCMR was preceded by significant elevations in gdcfDNA as quantified by both techniques. Elevations in gdcfDNA, using both techniques, were suggestive of TCMR in this pilot study with a 6- and 3-day lead-time prior to histological diagnosis in patients 1 and 2. Conclusions: Both the graft-specific methylation and genotyping techniques successfully quantified gdcfDNA in patients post-LT with statistically significant concordance. A direct comparison of these two techniques is not only important from a technical perspective for orthogonal validation, but significantly adds weight to the evidence that gdcfDNA monitoring reflects the underlying biology. Both techniques identified LT recipients who developed acute TCMR, with several days lead-time in comparison to conventional diagnostic workflows. Whilst the two assays performed comparably, gdcfDNA monitoring based on graft-specific DNA methylation patterns in cfDNA offers major practical advantages over the donor-recipient genotyping, and hence enhances the potential to translate this emerging technology into clinical practice.
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Affiliation(s)
- Daniel R A Cox
- Department of Surgery (Austin Precinct), University of Melbourne, Melbourne, VIC 3084, Australia
- HPB & Liver Transplant Surgery Unit, Department of Surgery, Austin Health, Melbourne, VIC 3084, Australia
- BEACON Biomarkers Laboratory, University of Melbourne, Melbourne, VIC 3084, Australia
| | - Tess McClure
- Department of Surgery (Austin Precinct), University of Melbourne, Melbourne, VIC 3084, Australia
- BEACON Biomarkers Laboratory, University of Melbourne, Melbourne, VIC 3084, Australia
- Liver Transplant Unit, Department of Gastroenterology & Hepatology, Austin Health, Melbourne, VIC 3084, Australia
| | - Fan Zhang
- BEACON Biomarkers Laboratory, University of Melbourne, Melbourne, VIC 3084, Australia
| | - Boris Ka Leong Wong
- BEACON Biomarkers Laboratory, University of Melbourne, Melbourne, VIC 3084, Australia
- School of Cancer Medicine, La Trobe University, Melbourne, VIC 3084, Australia
| | - Adam Testro
- Liver Transplant Unit, Department of Gastroenterology & Hepatology, Austin Health, Melbourne, VIC 3084, Australia
| | - Su Kah Goh
- Department of Surgery (Austin Precinct), University of Melbourne, Melbourne, VIC 3084, Australia
| | - Vijayaragavan Muralidharan
- Department of Surgery (Austin Precinct), University of Melbourne, Melbourne, VIC 3084, Australia
- HPB & Liver Transplant Surgery Unit, Department of Surgery, Austin Health, Melbourne, VIC 3084, Australia
- BEACON Biomarkers Laboratory, University of Melbourne, Melbourne, VIC 3084, Australia
| | - Alexander Dobrovic
- Department of Surgery (Austin Precinct), University of Melbourne, Melbourne, VIC 3084, Australia
- BEACON Biomarkers Laboratory, University of Melbourne, Melbourne, VIC 3084, Australia
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Bányász B, Antal J, Dénes B. False Positives in Brucellosis Serology: Wrong Bait and Wrong Pond? Trop Med Infect Dis 2023; 8:tropicalmed8050274. [PMID: 37235322 DOI: 10.3390/tropicalmed8050274] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/07/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
This review summarizes the status of resolving the problem of false positive serologic results (FPSR) in Brucella serology, compiles our knowledge on the molecular background of the problem, and highlights some prospects for its resolution. The molecular basis of the FPSRs is reviewed through analyzing the components of the cell wall of Gram-negative bacteria, especially the surface lipopolysaccharide (LPS) with details related to brucellae. After evaluating the efforts that have been made to solve target specificity problems of serologic tests, the following conclusions can be drawn: (i) resolving the FPSR problem requires a deeper understanding than we currently possess, both of Brucella immunology and of the current serology tests; (ii) the practical solutions will be as expensive as the related research; and (iii) the root cause of FPSRs is the application of the same type of antigen (S-type LPS) in the currently approved tests. Thus, new approaches are necessary to resolve the problems stemming from FPSR. Such approaches suggested by this paper are: (i) the application of antigens from R-type bacteria; or (ii) the further development of specific brucellin-based skin tests; or (iii) the application of microbial cell-free DNA as analyte, whose approach is detailed in this paper.
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Affiliation(s)
- Borbála Bányász
- Department of Microbiology and Infectious Diseases, University of Veterinary Medicine Budapest, 1143 Budapest, Hungary
- Laboratory of Immunology, Veterinary Diagnostic Directorate, National Food Chain Safety Office, 1143 Budapest, Hungary
| | - József Antal
- Omixon Biocomputing Ltd., 1117 Budapest, Hungary
| | - Béla Dénes
- Department of Microbiology and Infectious Diseases, University of Veterinary Medicine Budapest, 1143 Budapest, Hungary
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DeFilippis EM, Kransdorf EP, Jaiswal A, Zhang X, Patel J, Kobashigawa JA, Baran DA, Kittleson MM. Detection and management of HLA sensitization in candidates for adult heart transplantation. J Heart Lung Transplant 2023; 42:409-422. [PMID: 36631340 DOI: 10.1016/j.healun.2022.12.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/28/2022] Open
Abstract
Heart transplantation (HT) remains the preferred therapy for patients with advanced heart failure. However, for sensitized HT candidates who have antibodies to human leukocyte antigens , finding a suitable donor can be challenging and can lead to adverse waitlist outcomes. In recent years, the number of sensitized patients awaiting HT has increased likely due to the use of durable and mechanical circulatory support as well as increasing number of candidates with underlying congenital heart disease. This State-of-the-Art review discusses the assessment of human leukocyte antigens antibodies, potential desensitization strategies including mechanisms of action and specific protocols, the approach to a potential donor including the use of complement-dependent cytotoxicity, flow cytometry, and virtual crossmatches, and peritransplant induction management.
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Affiliation(s)
- Ersilia M DeFilippis
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Evan P Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Abhishek Jaiswal
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Xiaohai Zhang
- HLA and Immunogenetics Laboratory, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David A Baran
- Cleveland Clinic, Heart Vascular and Thoracic Institute, Weston, Florida
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43
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Holzhauser L, DeFilippis EM, Nikolova A, Byku M, Contreras JP, De Marco T, Hall S, Khush KK, Vest AR. The End of Endomyocardial Biopsy?: A Practical Guide for Noninvasive Heart Transplant Rejection Surveillance. JACC. HEART FAILURE 2023; 11:263-276. [PMID: 36682960 DOI: 10.1016/j.jchf.2022.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 01/13/2023]
Abstract
Noninvasive heart transplant rejection surveillance using gene expression profiling (GEP) to monitor immune activation is widely used among heart transplant programs. With the new development of donor-derived cell-free DNA (dd-cfDNA) assays, more programs are transitioning to a predominantly noninvasive rejection surveillance protocol with a reduced frequency of endomyocardial biopsies. As a result, many practical questions arise that potentially delay implementation of these valuable new tools. The purpose of this review is to provide practical guidance for clinicians transitioning toward a less invasive acute rejection monitoring protocol after heart transplantation, and to answer 10 common questions about the GEP and dd-cfDNA assays. Evidence supporting GEP and dd-cfDNA testing is reviewed, as well as guidance on test interpretation and future directions.
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Affiliation(s)
- Luise Holzhauser
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Andriana Nikolova
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mirnela Byku
- Department of Cardiology, University of North Carolina in Chapel Hill, North Carolina, USA
| | | | - Teresa De Marco
- Division of Cardiology, University of California, San Francisco, California, USA
| | - Shelley Hall
- Baylor University Medical Center, Dallas, Texas, USA
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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44
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Henricksen EJ, Moayedi Y, Purewal S, Twiggs JV, Waddell K, Luikart H, Han J, Feng K, Wayda B, Lee R, Shudo Y, Jimenez S, Khush KK, Teuteberg JJ. Combining donor derived cell free DNA and gene expression profiling for non-invasive surveillance after heart transplantation. Clin Transplant 2023; 37:e14699. [PMID: 35559582 DOI: 10.1111/ctr.14699] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/11/2022] [Accepted: 04/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Donor-derived cell free DNA (dd-cfDNA) and gene expression profiling (GEP) offer noninvasive alternatives to rejection surveillance after heart transplantation; however, there is little evidence on the paired use of GEP and dd-cfDNA for rejection surveillance. METHODS A single center, retrospective analysis of adult heart transplant recipients. A GEP cohort, transplanted from January 1, 2015 through December 31, 2017 and eligible for rejection surveillance with GEP was compared to a paired testing cohort, transplanted July 1, 2018 through June 30, 2020, with surveillance from both dd-cfDNA and GEP. The primary outcomes were survival and rejection-free survival at 1 year post-transplant. RESULTS In total 159 patients were included, 95 in the GEP and 64 in the paired testing group. There were no differences in baseline characteristics, except for less use of induction in the paired testing group (65.6%) compared to the GEP group (98.9%), P < .01. At 1-year, there were no differences between the paired testing and GEP groups in survival (98.4% vs. 94.7%, P = .23) or rejection-free survival (81.3% vs. 73.7% P = .28). CONCLUSIONS Compared to post-transplant rejection surveillance with GEP alone, pairing dd-cfDNA and GEP testing was associated with similar survival and rejection-free survival at 1 year while requiring significantly fewer biopsies.
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Affiliation(s)
| | - Yasbanoo Moayedi
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Saira Purewal
- University of Arizona College of Medicine, Tucson, Arizona, USA
| | | | - Kian Waddell
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Helen Luikart
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Jiho Han
- Internal Medicine, Stanford University, Stanford, California, USA
| | - Kent Feng
- Internal Medicine, Stanford University, Stanford, California, USA
| | - Brian Wayda
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Roy Lee
- Transplant, Stanford Health Care, Stanford, California, USA
| | - Yasuhiro Shudo
- Cardiovascular Surgery, Stanford University, Stanford, California, USA
| | - Shirin Jimenez
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Kiran K Khush
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
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45
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Adedinsewo D, Hardway HD, Morales-Lara AC, Wieczorek MA, Johnson PW, Douglass EJ, Dangott BJ, Nakhleh RE, Narula T, Patel PC, Goswami RM, Lyle MA, Heckman AJ, Leoni-Moreno JC, Steidley DE, Arsanjani R, Hardaway B, Abbas M, Behfar A, Attia ZI, Lopez-Jimenez F, Noseworthy PA, Friedman P, Carter RE, Yamani M. Non-invasive detection of cardiac allograft rejection among heart transplant recipients using an electrocardiogram based deep learning model. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2023; 4:71-80. [PMID: 36974261 PMCID: PMC10039431 DOI: 10.1093/ehjdh/ztad001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/08/2022] [Indexed: 01/15/2023]
Abstract
Aims Current non-invasive screening methods for cardiac allograft rejection have shown limited discrimination and are yet to be broadly integrated into heart transplant care. Given electrocardiogram (ECG) changes have been reported with severe cardiac allograft rejection, this study aimed to develop a deep-learning model, a form of artificial intelligence, to detect allograft rejection using the 12-lead ECG (AI-ECG). Methods and results Heart transplant recipients were identified across three Mayo Clinic sites between 1998 and 2021. Twelve-lead digital ECG data and endomyocardial biopsy results were extracted from medical records. Allograft rejection was defined as moderate or severe acute cellular rejection (ACR) based on International Society for Heart and Lung Transplantation guidelines. The extracted data (7590 unique ECG-biopsy pairs, belonging to 1427 patients) was partitioned into training (80%), validation (10%), and test sets (10%) such that each patient was included in only one partition. Model performance metrics were based on the test set (n = 140 patients; 758 ECG-biopsy pairs). The AI-ECG detected ACR with an area under the receiver operating curve (AUC) of 0.84 [95% confidence interval (CI): 0.78-0.90] and 95% (19/20; 95% CI: 75-100%) sensitivity. A prospective proof-of-concept screening study (n = 56; 97 ECG-biopsy pairs) showed the AI-ECG detected ACR with AUC = 0.78 (95% CI: 0.61-0.96) and 100% (2/2; 95% CI: 16-100%) sensitivity. Conclusion An AI-ECG model is effective for detection of moderate-to-severe ACR in heart transplant recipients. Our findings could improve transplant care by providing a rapid, non-invasive, and potentially remote screening option for cardiac allograft function.
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Affiliation(s)
- Demilade Adedinsewo
- Department of Cardiovascular Medicine, Division of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Heather D Hardway
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Andrea Carolina Morales-Lara
- Department of Cardiovascular Medicine, Division of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Mikolaj A Wieczorek
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Patrick W Johnson
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Erika J Douglass
- Department of Cardiovascular Medicine, Division of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Bryan J Dangott
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Raouf E Nakhleh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Tathagat Narula
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Parag C Patel
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Rohan M Goswami
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Melissa A Lyle
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Alexander J Heckman
- Department of Cardiovascular Medicine, Division of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | | | - D Eric Steidley
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Brian Hardaway
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Mohsin Abbas
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Zachi I Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Paul Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rickey E Carter
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | - Mohamad Yamani
- Department of Cardiovascular Medicine, Division of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
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Kittleson MM, DeFilippis EM, Bhagra CJ, Casale JP, Cauldwell M, Coscia LA, D'Souza R, Gaffney N, Gerovasili V, Ging P, Horsley K, Macera F, Mastrobattista JM, Paraskeva MA, Punnoose LR, Rasmusson KD, Reynaud Q, Ross HJ, Thakrar MV, Walsh MN. Reproductive health after thoracic transplantation: An ISHLT expert consensus statement. J Heart Lung Transplant 2023; 42:e1-e42. [PMID: 36528467 DOI: 10.1016/j.healun.2022.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Catriona J Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - Jillian P Casale
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
| | - Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Lisa A Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Gaffney
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kristin Horsley
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Joan M Mastrobattista
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine Houston, Texas
| | - Miranda A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Lynn R Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Quitterie Reynaud
- Cystic Fibrosis Adult Referral Care Centre, Department of Internal Medicine, Hospices civils de Lyon, Pierre Bénite, France
| | - Heather J Ross
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Thakrar
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
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Clausen FB, Jørgensen KMCL, Wardil LW, Nielsen LK, Krog GR. Droplet digital PCR-based testing for donor-derived cell-free DNA in transplanted patients as noninvasive marker of allograft health: Methodological aspects. PLoS One 2023; 18:e0282332. [PMID: 36827438 PMCID: PMC9955980 DOI: 10.1371/journal.pone.0282332] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/13/2023] [Indexed: 02/26/2023] Open
Abstract
In solid organ transplantation, donor-derived cell-free DNA (dd-cfDNA) is a promising universal noninvasive biomarker for allograft health, where high levels of dd-cfDNA indicate organ damage. Using Droplet Digital PCR (ddPCR), we aimed to develop an assay setup for monitoring organ health. We aimed to identify the least distinguishable percentage-point increase in the fraction of minute amounts of cfDNA in a large cfDNA background by using assays targeting single nucleotide polymorphisms (SNPs). We mimicked a clinical sample from a recipient in a number of spike-in experiments, where cfDNA from healthy volunteers were mixed. A total of 40 assays were tested and approved by qPCR and ddPCR. Limit of detection (LOD) was demonstrated to be approximately 3 copies per reaction, observed at a fraction of 0.002%, and which would equal 6 copies per mL plasma. Limit of quantification (LOQ) was 35 copies per reaction, estimated to 0.038%. The lowest detectable increase in percentage point of dd-cfDNA was approximately 0.04%. Our results demonstrated that ddPCR has great sensitivity, high precision, and exceptional ability to quantify low levels of cfDNA. The ability to distinguish small differences in mimicking dd-cfDNA was far beyond the desired capability. While these methodological data are promising, further prospective studies are needed to determine the clinical utility of the proposed method.
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Affiliation(s)
- Frederik Banch Clausen
- Department of Clinical Immunology, Copenhagen University Hospital, Copenhagen, Denmark
- * E-mail:
| | - Kristine Mathilde Clara Lund Jørgensen
- Department of Clinical Immunology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Technology, Faculty of Health, University College Copenhagen, Copenhagen, Denmark
| | - Lasse Witt Wardil
- Department of Clinical Immunology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Technology, Faculty of Health, University College Copenhagen, Copenhagen, Denmark
| | - Leif Kofoed Nielsen
- Department of Technology, Faculty of Health, University College Copenhagen, Copenhagen, Denmark
| | - Grethe Risum Krog
- Department of Clinical Immunology, Copenhagen University Hospital, Copenhagen, Denmark
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Feingold B, Rose-Felker K, West SC, Miller SA, Zinn MD. Short-term clinical outcomes and predicted cost savings of dd-cfDNA-led surveillance after pediatric heart transplantation. Clin Transplant 2023; 37:e14933. [PMID: 36779524 DOI: 10.1111/ctr.14933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/30/2023] [Accepted: 02/08/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Endomyocardial biopsy (EMB)-led surveillance is common after pediatric heart transplantation (HT), with some centers performing periodic surveillance EMBs indefinitely after HT. Donor derived cell-free DNA (dd-cfDNA)-led surveillance offers an alternative, but knowledge about its clinical and economic outcomes, both key drivers of potential utilization, are lacking. METHODS Using single-center recipient and center-level data, we describe clinical outcomes prior to and since transition from EMB-led surveillance to dd-cfDNA-led surveillance of pediatric and young adult HT recipients. These data were then used to inform Markov models to compare costs between EMB-led and dd-cfDNA-led surveillance strategies. RESULTS Over 34.5 months, dd-cfDNA-led surveillance decreased the number of EMBs by 81.8% (95% CI 76.3%-86.5%) among 120 HT recipients (median age 13.3 years). There were no differences in the incidences of graft loss or death among all recipients followed at our center prior to and following implementation of dd-cfDNA-led surveillance (graft loss: 2.9 vs. 1.5 per 100 patient-years; p = .17; mortality: 3.7 vs. 2.2 per 100 patient-years; p = .23). Over 20 years from HT, dd-cfDNA-led surveillance is projected to cost $8545 less than EMB-led surveillance. Model findings were robust in sensitivity and scenario analyses, with cost of EMB, cost of dd-cfDNA testing, and probability of elevated dd-cfDNA most influential on model findings. CONCLUSIONS dd-cfDNA-led surveillance shows promise as a less invasive and cost saving alternative to EMB-led surveillance among pediatric and young adult HT recipients.
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Affiliation(s)
- Brian Feingold
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kirsten Rose-Felker
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shawn C West
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Susan A Miller
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew D Zinn
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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49
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Richmond ME, Deshpande SR, Zangwill SD, Bichell DP, Kindel SJ, Mahle WT, Schroder JN, Wigger MA, Knecht KR, Pahl E, Gaglianello NA, Goetsch MA, Simpson P, Dasgupta M, Zhang L, North PE, Tomita-Mitchell A, Mitchell ME. Validation of donor fraction cell-free DNA with biopsy-proven cardiac allograft rejection in children and adults. J Thorac Cardiovasc Surg 2023; 165:460-468.e2. [PMID: 35643770 PMCID: PMC9617812 DOI: 10.1016/j.jtcvs.2022.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 04/04/2022] [Accepted: 04/19/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Donor-specific cell-free DNA shows promise as a noninvasive marker for allograft rejection, but as yet has not been validated in both adult and pediatric recipients. The study objective was to validate donor fraction cell-free DNA as a noninvasive test to assess for risk of acute cellular rejection and antibody-mediated rejection after heart transplantation in pediatric and adult recipients. METHODS Pediatric and adult heart transplant recipients were enrolled from 7 participating sites and followed for 12 months or more with plasma samples collected immediately before all endomyocardial biopsies. Donor fraction cell-free DNA was extracted, and quantitative genotyping was performed. Blinded donor fraction cell-free DNA and clinical data were analyzed and compared with a previously determined threshold of 0.14%. Sensitivity, specificity, negative predictive value, positive predictive value, and receiver operating characteristic curves were calculated. RESULTS A total of 987 samples from 144 subjects were collected. After applying predefined clinical and technical exclusions, 745 samples from 130 subjects produced 54 rejection samples associated with the composite outcome of acute cellular rejection grade 2R or greater and pathologic antibody-mediated rejection 2 or greater and 323 healthy samples. For all participants, donor fraction cell-free DNA at a threshold of 0.14% had a sensitivity of 67%, a specificity of 79%, a positive predictive value of 34%, and a negative predictive value of 94% with an area under the curve of 0.78 for detecting rejection. When analyzed independently, these results held true for both pediatric and adult cohorts at the same threshold of 0.14% (negative predictive value 92% and 95%, respectively). CONCLUSIONS Donor fraction cell-free DNA at a threshold of 0.14% can be used to assess for risk of rejection after heart transplantation in both pediatric and adult patients with excellent negative predictive value.
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Affiliation(s)
- Marc E Richmond
- Division of Pediatric Cardiology, Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
| | - Shriprasad R Deshpande
- Division of Pediatric Cardiology, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | | | - David P Bichell
- Division of Pediatric Cardiac Surgery, Department of Surgery, Vanderbilt University, Nashville, Tenn
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wis
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Mark A Wigger
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tenn
| | - Kenneth R Knecht
- Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Ark
| | | | | | - Mary A Goetsch
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Pippa Simpson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Mahua Dasgupta
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Liyun Zhang
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Paula E North
- Department of Pathology, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wis
| | - Aoy Tomita-Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wis
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wis
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Kueng N, Arcioni S, Sandberg F, Kuhn C, Banz V, Largiadèr CR, Sidler D, Amstutz U. Comparison of methods for donor-derived cell-free DNA quantification in plasma and urine from solid organ transplant recipients. Front Genet 2023; 14:1089830. [PMID: 36777723 PMCID: PMC9916053 DOI: 10.3389/fgene.2023.1089830] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/12/2023] [Indexed: 01/28/2023] Open
Abstract
In allograft monitoring of solid organ transplant recipients, liquid biopsy has emerged as a novel approach using quantification of donor-derived cell-free DNA (dd-cfDNA) in plasma. Despite early clinical implementation and analytical validation of techniques, direct comparisons of dd-cfDNA quantification methods are lacking. Furthermore, data on dd-cfDNA in urine is scarce and high-throughput sequencing-based methods so far have not leveraged unique molecular identifiers (UMIs) for absolute dd-cfDNA quantification. Different dd-cfDNA quantification approaches were compared in urine and plasma of kidney and liver recipients: A) Droplet digital PCR (ddPCR) using allele-specific detection of seven common HLA-DRB1 alleles and the Y chromosome; B) high-throughput sequencing (HTS) using a custom QIAseq DNA panel targeting 121 common polymorphisms; and C) a commercial dd-cfDNA quantification method (AlloSeq® cfDNA, CareDx). Dd-cfDNA was quantified as %dd-cfDNA, and for ddPCR and HTS using UMIs additionally as donor copies. In addition, relative and absolute dd-cfDNA levels in urine and plasma were compared in clinically stable recipients. The HTS method presented here showed a strong correlation of the %dd-cfDNA with ddPCR (R 2 = 0.98) and AlloSeq® cfDNA (R 2 = 0.99) displaying only minimal to no proportional bias. Absolute dd-cfDNA copies also correlated strongly (τ = 0.78) between HTS with UMI and ddPCR albeit with substantial proportional bias (slope: 0.25; 95%-CI: 0.19-0.26). Among 30 stable kidney transplant recipients, the median %dd-cfDNA in urine was 39.5% (interquartile range, IQR: 21.8-58.5%) with 36.6 copies/μmol urinary creatinine (IQR: 18.4-109) and 0.19% (IQR: 0.01-0.43%) with 5.0 copies/ml (IQR: 1.8-12.9) in plasma without any correlation between body fluids. The median %dd-cfDNA in plasma from eight stable liver recipients was 2.2% (IQR: 0.72-4.1%) with 120 copies/ml (IQR: 85.0-138) while the median dd-cfDNA copies/ml was below 0.1 in urine. This first head-to-head comparison of methods for absolute and relative quantification of dd-cfDNA in urine and plasma supports a method-independent %dd-cfDNA cutoff and indicates the suitability of the presented HTS method for absolute dd-cfDNA quantification using UMIs. To evaluate the utility of dd-cfDNA in urine for allograft surveillance, absolute levels instead of relative amounts will most likely be required given the extensive variability of %dd-cfDNA in stable kidney recipients.
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Affiliation(s)
- Nicholas Kueng
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Séverine Arcioni
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- Division of Medical Genetics, Central Institute of Hospitals, Valais Hospital, Sion, Switzerland
| | - Fanny Sandberg
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Christian Kuhn
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Vanessa Banz
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Carlo R. Largiadèr
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Daniel Sidler
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Ursula Amstutz
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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