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Akifova A, Budde K, Oellerich M, Beck J, Bornemann-Kolatzki K, Schütz E, Osmanodja B. Perspective for Donor-Derived Cell-Free DNA in Antibody-Mediated Rejection After Kidney Transplantation: Defining Context of Use and Clinical Implications. Transpl Int 2024; 37:13239. [PMID: 39188271 PMCID: PMC11345135 DOI: 10.3389/ti.2024.13239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 07/30/2024] [Indexed: 08/28/2024]
Abstract
Antibody-mediated rejection (AMR) is a major cause of graft failure limiting long-term graft survival after kidney transplantation. Current diagnostic strategy to detect AMR is suboptimal and requires further improvement. Previously suggested treatment regimens for AMR could not demonstrate efficacy, however novel therapeutic agents are currently under investigation. Donor-derived cell-free DNA (dd-cfDNA) is a novel non-invasive biomarker for allograft injury, that has been mainly studied in the context of rejection. Its short-half-life in circulation and injury-dependent release are its key advantages that contribute to its superior diagnostic accuracy, compared to traditional biomarkers. Moreover, previous studies showed that dd-cfDNA-release is well-linked to histological and molecular features of AMR, and thus able to reflect real-time injury. Further observations suggest that dd-cfDNA can be used as a suitable screening tool for early detection of AMR in patients with donor-specific-anti-HLA-antibodies (DSA), as well as for monitoring AMR activity after anti-rejection treatment. The weight of evidence suggests that the integration of dd-cfDNA in the graft surveillance of patients with AMR, or those suspicious of AMR (e.g., due to the presence of donor-specific anti-HLA-antibodies) has an added value and might have a positive impact on outcomes in this specific cohort.
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Affiliation(s)
- Aylin Akifova
- Department of Nephrology and Intensive Care, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Intensive Care, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Oellerich
- Department of Clinical Pharmacology, University Medical Center Göttingen, Göttingen, Germany
| | - Julia Beck
- Chronix Biomedical GmbH, Göttingen, Germany
| | | | | | - Bilgin Osmanodja
- Department of Nephrology and Intensive Care, Charité—Universitätsmedizin Berlin, Berlin, Germany
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2
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Balakrishnan S, Alexander MP, Schinstock C. Challenges and opportunities for designing clinical trials for antibody mediated rejection. FRONTIERS IN TRANSPLANTATION 2024; 3:1389005. [PMID: 38993760 PMCID: PMC11235363 DOI: 10.3389/frtra.2024.1389005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/25/2024] [Indexed: 07/13/2024]
Abstract
Significant progress has been made in kidney transplantation, with 1-year graft survival nearing 95%. However, long-term allograft survival remains suboptimal, with a 10-year overall graft survival rate of only 53.6% for deceased donor transplant recipients. Chronic active antibody-mediated rejection (ABMR) is a leading cause of death-censored graft loss, yet no therapy has demonstrated efficacy in large, randomized trials, despite substantial investment from pharmaceutical companies. Several clinical trials aimed to treat chronic ABMR in the past decade have yielded disappointing results or were prematurely terminated, attributed to factors including incomplete understanding of disease mechanisms, heterogeneous patient populations with comorbidities, slow disease progression, and limited patient numbers. This review aims to discuss opportunities for improving retrospective and prospective studies of ABMR, focusing on addressing heterogeneity, outcome measurement, and strategies to enhance patient enrollment to inform study design, data collection, and reporting.
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Affiliation(s)
- Suryanarayanan Balakrishnan
- Division of Hypertension and Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Carrie Schinstock
- Division of Hypertension and Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
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3
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Peng H, Pan M, Zhou Z, Chen C, Xing X, Cheng S, Zhang S, Zheng H, Qian K. The impact of preanalytical variables on the analysis of cell-free DNA from blood and urine samples. Front Cell Dev Biol 2024; 12:1385041. [PMID: 38784382 PMCID: PMC11111958 DOI: 10.3389/fcell.2024.1385041] [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: 02/11/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Cell-free DNA (cfDNA), a burgeoning class of molecular biomarkers, has been extensively studied across a variety of biomedical fields. As a key component of liquid biopsy, cfDNA testing is gaining prominence in disease detection and management due to the convenience of sample collection and the abundant wealth of genetic information it provides. However, the broader clinical application of cfDNA is currently impeded by a lack of standardization in the preanalytical procedures for cfDNA analysis. A number of fundamental challenges, including the selection of appropriate preanalytical procedures, prevention of short cfDNA fragment loss, and the validation of various cfDNA measurement methods, remain unaddressed. These existing hurdles lead to difficulties in comparing results and ensuring repeatability, thereby undermining the reliability of cfDNA analysis in clinical settings. This review discusses the crucial preanalytical factors that influence cfDNA analysis outcomes, including sample collection, transportation, temporary storage, processing, extraction, quality control, and long-term storage. The review provides clarification on achievable consensus and offers an analysis of the current issues with the goal of standardizing preanalytical procedures for cfDNA analysis.
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Affiliation(s)
- Hongwei Peng
- Department of Biological Repositories, Human Genetic Resources Preservation Center of Hubei Province, Hubei Key Laboratory of Urological Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ming Pan
- Taihe Skills Training Center, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Zongning Zhou
- Department of Biological Repositories, Human Genetic Resources Preservation Center of Hubei Province, Hubei Key Laboratory of Urological Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Congbo Chen
- Department of Urology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Xing Xing
- Department of Urology, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei, China
| | - Shaoping Cheng
- Department of Urology, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei, China
| | - Shanshan Zhang
- Department of Biological Repositories, Human Genetic Resources Preservation Center of Hubei Province, Hubei Key Laboratory of Urological Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hang Zheng
- Department of Urology, Laboratory of Precision Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Kaiyu Qian
- Department of Biological Repositories, Human Genetic Resources Preservation Center of Hubei Province, Hubei Key Laboratory of Urological Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
- Department of Urology, Laboratory of Precision Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
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4
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Ranch D, Fei M, Kincade E, Piburn K, Hitchman K, Klein K. Utilization of donor-derived Cell-Free DNA in pediatric kidney transplant recipients: A single center study. Pediatr Transplant 2024; 28:e14582. [PMID: 37550268 DOI: 10.1111/petr.14582] [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: 04/07/2023] [Revised: 06/02/2023] [Accepted: 07/07/2023] [Indexed: 08/09/2023]
Abstract
High donor-derived cell-free DNA (dd-cfDNA) levels indicate transplant allograft injury and can identify graft rejection in kidney transplant recipients. Here, we evaluated the use of dd-cfDNA in pediatric kidney transplant rejection monitoring and treatment. METHODS Forty-two pediatric kidney transplant patients were enrolled between February 2020 and August 2021. Dd-cfDNA was tested before and after biopsy/rejection treatment. There was a total of 61 allograft biopsies (44 for-cause, 17 surveillance). RESULTS Graft rejection was found in 35/61 biopsies. Rejection was more common in basiliximab induction compared to rATG (77.1% vs. 22.9%, p = .0121). Median dd-cfDNA was higher in those with rejection (1.2% [0.34-3.12] vs. 0.24% [0.08-0.78], p < .0001). Dd-cfDNA was highest in biopsies with AMR and mixed AMR/TCMR. In addition, dd-cfDNA in basiliximab induction was higher compared to rATG (0.92% [0.27-1.8] vs. 0.26% [0.08-2], p = .0437). Median change in dd-cfDNA after rejection treatment was -0.57% (-1.67 to 0.05). Median time to dd-cfDNA <1% post-rejection treatment was 8.5 days (3.0-19.5). Dd-cfDNA in AMR was higher compared to TCMR or mixed rejection, and levels remained higher in AMR after treatment. In surveillance biopsies, 4/17 had rejection. Median dd-cfDNA was not different in those with versus without rejection (0.48% vs. 0.28%, p = .2342). Those without rejection all had dd-cfDNA <1%. In those with rejection, only one patient had dd-cfDNA >1%, and all had TCMR. CONCLUSIONS Our findings support dd-cfDNA as a useful indicator of graft rejection and response to treatment. Additional studies are needed to determine the role of dd-cfDNA in graft health surveillance.
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Affiliation(s)
- Daniel Ranch
- Department of Pediatrics, UT Health San Antonio, San Antonio, Texas, USA
| | - Mingwei Fei
- Biostatistics Department, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elisabeth Kincade
- University Health Transplant Institute, San Antonio, Texas, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Kim Piburn
- Department of Pediatrics, UT Health San Antonio, San Antonio, Texas, USA
| | - Kelley Hitchman
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas, USA
| | - Kelsey Klein
- University Health Transplant Institute, San Antonio, Texas, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
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5
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Pradère P, Zajacova A, Bos S, Le Pavec J, Fisher A. Molecular monitoring of lung allograft health: is it ready for routine clinical use? Eur Respir Rev 2023; 32:230125. [PMID: 37993125 PMCID: PMC10663940 DOI: 10.1183/16000617.0125-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/16/2023] [Indexed: 11/24/2023] Open
Abstract
Maintenance of long-term lung allograft health in lung transplant recipients (LTRs) requires a fine balancing act between providing sufficient immunosuppression to reduce the risk of rejection whilst at the same time not over-immunosuppressing individuals and exposing them to the myriad of immunosuppressant drug side-effects that can cause morbidity and mortality. At present, lung transplant physicians only have limited and rather blunt tools available to assist them with this task. Although therapeutic drug monitoring provides clinically useful information about single time point and longitudinal exposure of LTRs to immunosuppressants, it lacks precision in determining the functional level of immunosuppression that an individual is experiencing. There is a significant gap in our ability to monitor lung allograft health and therefore tailor optimal personalised immunosuppression regimens. Molecular diagnostics performed on blood, bronchoalveolar lavage or lung tissue that can detect early signs of subclinical allograft injury, differentiate rejection from infection or distinguish cellular from humoral rejection could offer clinicians powerful tools in protecting lung allograft health. In this review, we look at the current evidence behind molecular monitoring in lung transplantation and ask if it is ready for routine clinical use. Although donor-derived cell-free DNA and tissue transcriptomics appear to be the techniques with the most immediate clinical potential, more robust data are required on their performance and additional clinical value beyond standard of care.
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Affiliation(s)
- Pauline Pradère
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Department of Respiratory Diseases, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Paris, France
| | - Andrea Zajacova
- Prague Lung Transplant Program, Department of Pneumology, Motol University Hospital and 2nd Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Jérôme Le Pavec
- Department of Respiratory Diseases, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Paris, France
| | - Andrew Fisher
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
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6
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Benning L, Morath C, Fink A, Rudek M, Speer C, Kälble F, Nusshag C, Beimler J, Schwab C, Waldherr R, Zeier M, Süsal C, Tran TH. Donor-Derived Cell-Free DNA (dd-cfDNA) in Kidney Transplant Recipients With Indication Biopsy-Results of a Prospective Single-Center Trial. Transpl Int 2023; 36:11899. [PMID: 38020751 PMCID: PMC10654198 DOI: 10.3389/ti.2023.11899] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023]
Abstract
Donor-derived cell-free DNA (dd-cfDNA) identifies allograft injury and discriminates active rejection from no rejection. In this prospective study, 106 kidney transplant recipients with 108 clinically indicated biopsies were enrolled at Heidelberg University Hospital between November 2020 and December 2022 to validate the clinical value of dd-cfDNA in a cohort of German patients. dd-cfDNA was quantified at biopsy and correlated to histopathology. Additionally, dd-cfDNA was determined on days 7, 30, and 90 post-biopsy and analyzed for potential use to monitor response to anti-rejection treatment. dd-cfDNA levels were with a median (IQR) % of 2.00 (0.48-3.20) highest in patients with ABMR, followed by 0.92 (0.19-11.25) in patients with TCMR, 0.44 (0.20-1.10) in patients with borderline changes and 0.20 (0.11-0.53) in patients with no signs of rejection. The AUC for dd-cfDNA to discriminate any type of rejection including borderline changes from no rejection was at 0.72 (95% CI 0.62-0.83). In patients receiving anti-rejection treatment, dd-cfDNA levels significantly decreased during the 7, 30, and 90 days follow-up compared to levels at the time of biopsy (p = 0.006, p = 0.002, and p < 0.001, respectively). In conclusion, dd-cfDNA significantly discriminates active rejection from no rejection. Decreasing dd-cfDNA following anti-rejection treatment may indicate response to therapy. Clinical Trial Registration: https://drks.de/search/de/trial/DRKS00023604, identifier DRKS00023604.
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Affiliation(s)
- Louise Benning
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Annette Fink
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus Rudek
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Claudius Speer
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Kälble
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Nusshag
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jörg Beimler
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Constantin Schwab
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Rüdiger Waldherr
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
- Transplant Immunology Research Center of Excellence, Koç University Hospital, Istanbul, Türkiye
| | - Thuong Hien Tran
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
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7
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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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8
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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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9
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Graver AS, Lee D, Power DA, Whitlam JB. Understanding Donor-derived Cell-free DNA in Kidney Transplantation: An Overview and Case-based Guide for Clinicians. Transplantation 2023; 107:1675-1686. [PMID: 36579675 DOI: 10.1097/tp.0000000000004482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Kidney transplant recipients undergo lifelong monitoring of allograft function and evaluation for transplant complications. The current monitoring paradigm utilizes blood, urine, and tissue markers that are insensitive, nonspecific, or invasive to obtain. As a result, problems are detected late, after significant damage has accrued, and often beyond the time at which complete resolution is possible. Indeed, most kidney transplants eventually fail, usually because of chronic rejection and other undetected injury. There is a clear need for a transplant-specific biomarker that enables a proactive approach to monitoring via early detection of reversible pathology. A biomarker that supports timely and personalized treatment would assist in achieving the ultimate goal of improving allograft survival and limiting therapeutic toxicity to the recipient. Donor-derived cell-free DNA (ddcfDNA) has been proposed as one such transplant biomarker. Although the test is presently utilized most in the United States, it is conceivable that its use will become more widespread. This review covers aspects of ddcfDNA that support informed use of the test by general nephrologists, including the basic biology of ddcfDNA, methodological nuances of testing, and general recommendations for use in the kidney transplant population. Clinical contexts are used to illustrate evidence-supported interpretation of ddcfDNA results and subsequent management. Finally, knowledge gaps and areas for further study are discussed.
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Affiliation(s)
- Alison S Graver
- Kidney Transplant Service, Department of Nephrology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Darren Lee
- Kidney Transplant Service, Department of Nephrology, Austin Health, Heidelberg, VIC, Australia
- Department of Renal Medicine, Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - David A Power
- Kidney Transplant Service, Department of Nephrology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - John B Whitlam
- Kidney Transplant Service, Department of Nephrology, Austin Health, Heidelberg, VIC, Australia
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia
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10
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Rizvi A, Faiz S, Thakkar PH, Hussain S, Gamilla-Crudo AN, Kueht M, Mujtaba MA. Kidney Allograft Monitoring by Combining Donor-Derived Cell-Free DNA and Molecular Gene Expression: A Clinical Management Perspective. J Pers Med 2023; 13:1205. [PMID: 37623456 PMCID: PMC10455393 DOI: 10.3390/jpm13081205] [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: 07/07/2023] [Revised: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023] Open
Abstract
Donor-derived cell-free DNA (dd-cfDNA) may safely assess kidney allograft rejection. Molecular Microscope (MMDx®) gene expression may offer increased precision to histology. This single-center retrospective study monitored kidney transplant recipients for rejection at specified time intervals by utilizing creatinine (SCr), proteinuria, donor-specific antibodies (DSAs), and dd-cfDNA. A clinically indicated biopsy sample was sent for histopathology and MMDx®. Patients were categorized into rejection (Rej) and non-rejection (NRej) groups, and further grouped according to antibody-mediated rejection (ABMR) subtypes. Rej and NRej groups included 52 and 37 biopsies, respectively. Median follow-up duration was 506 days. DSAs were positive in 53% and 22% of patients in both groups, respectively (p = 0.01). Among these groups, pre- and post-intervention median SCr, proteinuria, and dd-cfDNA at 1 month, 2 months, and at the last follow-up revealed significant difference for dd-cfDNA (all p = 0.01), however, no difference was found for SCr and proteinuria (p > 0.05). The AUC was 0.80 (95% CI: 0.69-0.91), with an optimal dd-cfDNA criterion of 2.2%. Compared to histology, MMDx® was more likely to diagnose ABMR (79% vs. 100%) with either C4d positivity or negativity and/or DSA positivity or negativity. Hence, a pre- and post-intervention allograft monitoring protocol in combination with dd-cfDNA, MMDx®, and histology has aided in early diagnosis and timely individualized intervention.
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Affiliation(s)
- Asim Rizvi
- Department of Nephrology, Hypertension and Transplant Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA; (A.R.); (P.H.T.); (S.H.); (A.N.G.-C.)
| | - Sara Faiz
- Department of Pathology, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Parin H. Thakkar
- Department of Nephrology, Hypertension and Transplant Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA; (A.R.); (P.H.T.); (S.H.); (A.N.G.-C.)
| | - Syed Hussain
- Department of Nephrology, Hypertension and Transplant Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA; (A.R.); (P.H.T.); (S.H.); (A.N.G.-C.)
| | - Ann N. Gamilla-Crudo
- Department of Nephrology, Hypertension and Transplant Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA; (A.R.); (P.H.T.); (S.H.); (A.N.G.-C.)
| | - Michael Kueht
- Department of Transplant Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA;
| | - Muhammad A. Mujtaba
- Department of Nephrology, Hypertension and Transplant Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX 77555, USA; (A.R.); (P.H.T.); (S.H.); (A.N.G.-C.)
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11
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Nassar A, Cashman K, Rao S, Dagher M, O'Brien C, Afif J, Cravedi P, Azzi JR. Liquid biopsy for non-invasive monitoring of patients with kidney transplants. FRONTIERS IN TRANSPLANTATION 2023; 2:1148725. [PMID: 38993899 PMCID: PMC11235308 DOI: 10.3389/frtra.2023.1148725] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/17/2023] [Indexed: 07/13/2024]
Abstract
The current tools for diagnosing and monitoring native kidney diseases as well as allograft rejection in transplant patients are suboptimal. Creatinine and proteinuria are non-specific and poorly sensitive markers of injury. Tissue biopsies are invasive and carry potential complications. In this article, we overview the different techniques of liquid biopsy and discuss their potential to improve patients' kidney health. Several diagnostic, predictive, and prognostic biomarkers have been identified with the ability to detect and monitor the activity of native kidney diseases as well as early and chronic allograft rejection, such as donor-derived cell-free DNA, exosomes, messenger RNA/microsomal RNA, proteomics, and so on. While the results are encouraging, additional research is still needed as no biomarker appears to be perfect for a routine application in clinical practice. Despite promising advancements in biomarkers, the most important issue is the lack of standardized pre-analytical criteria. Large validation studies and uniformed standard operating procedures are required to move the findings from bench to bedside. Establishing consortia such as the Liquid Biopsy Consortium for Kidney Diseases can help expedite the research process, allow large studies to establish standardized procedures, and improve the management and outcomes of kidney diseases and of kidney transplant recipients.
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Affiliation(s)
- Anthony Nassar
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, MA, United States
| | - Katharine Cashman
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, MA, United States
| | - Shreya Rao
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, MA, United States
| | - Maribel Dagher
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, MA, United States
| | - Connor O'Brien
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, MA, United States
| | - John Afif
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, MA, United States
| | - Paolo Cravedi
- Division of Nephrology, Department of Medicine, Translational Transplant Research Center, Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jamil R Azzi
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Boston, MA, United States
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12
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Parajuli S, Zhong W, Pantha M, Sokup M, Aziz F, Garg N, Mohamed M, Mandelbrot D. The Trend of Serum Creatinine Does Not Predict Follow-Up Biopsy Findings Among Kidney Transplant Recipients With Antibody-Mediated Rejection. Transplant Direct 2023; 9:e1489. [PMID: 37250486 PMCID: PMC10212615 DOI: 10.1097/txd.0000000000001489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 03/23/2023] [Indexed: 05/31/2023] Open
Abstract
Traditionally, antibody-mediated rejection (AMR) has been suspected mainly by a rise in serum creatinine (Scr) and confirmed by allograft biopsy. There is limited literature describing the trend of Scr after treatment, and how that trend might differ between patients with histological response and with no response to treatment. Methods We included all cases of AMR at our program between March 2016 and July 2020 who had a follow-up biopsy after the index biopsy, with initial diagnosis of AMR. We trended the Scr and change in Scr (delta Scr) and its association with being a responder (microvascular inflammation, MVI ≤1) or nonresponder (MVI >1), as well as graft failure. Results A total of 183 kidney transplant recipients were included, 66 in the responder group and 177 in the nonresponder group. The MVI scores and sum chronicity scores, along with transplant glomerulopathy scores, were higher in the nonresponder group. However, Scr at index biopsy was similar in responders (1.74 ± 0.70) versus nonresponders (1.83 ± 0.65; P = 0.39), as were the delta Scr at various time points. After adjustment for multiple variables, delta Scr was not associated with being a nonresponder. Also, delta Scr value at follow-up biopsy compared with index biopsy among responders was 0 ± 0.67 (P = 0.99) and among nonresponders was -0.01 ± 0.61 (P = 0.89). Being a nonresponder was significantly associated with an increased risk of graft failure at the last follow-up in univariate analysis but was not in multivariate analysis (hazard ratio 1.35; 95% confidence interval, 0.58-3.17; P = 0.49). Conclusions We found that Scr is not a good predictor of the resolution of MVI, supporting the utility of follow-up biopsies after treatment of AMR.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Weixiong Zhong
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Monika Pantha
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Megan Sokup
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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13
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Atlas-Lazar A, Levy-Erez D. Approach to acute kidney injury following paediatric kidney transplant. Curr Opin Pediatr 2023; 35:268-274. [PMID: 36591982 DOI: 10.1097/mop.0000000000001216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW In a child with evidence of acute kidney injury (AKI) following renal transplantation, it is important to quickly and accurately diagnose the cause to enable timely initiation of therapeutic interventions. The following article will discuss the differential diagnosis of acute graft dysfunction in paediatric kidney transplant recipients. This review will systematically guide the clinician through the common and less common causes and provide updates on current treatments. RECENT FINDINGS In patients with signs of graft dysfunction, rejection is an important cause to consider. Diagnosis of rejection relies on biopsy findings, an invasive and costly technique. Over the past 5 years, there has been a focus on noninvasive methods of diagnosing rejection, including serum and urinary biomarkers. SUMMARY This review discusses the differential diagnosis of acute graft dysfunction following transplant, with a focus on acute rejection, urinary tract infections and common viral causes, prerenal and postrenal causes, nephrotoxic medications, specifically calcineurin inhibitor toxicity, thrombotic microangiopathy and recurrence of the underlying disease. Each condition is discussed in detail, with a focus on clinical clues to the cause, incidence in the paediatric population, workup and treatment.
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Affiliation(s)
| | - Daniella Levy-Erez
- Schneider Children's Medical Center in Israel, Petah Tikva
- Tel Aviv, University School of Medicine, Tel Aviv, Israel
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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14
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Anti-interleukin-6 Antibody Clazakizumab in Antibody-mediated Kidney Transplant Rejection: Effect on Donor-derived Cell-free DNA and C-X-C Motif Chemokine Ligand 10. Transplant Direct 2022; 8:e1406. [PMID: 36382130 PMCID: PMC9649278 DOI: 10.1097/txd.0000000000001406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/18/2022] [Indexed: 11/29/2022] Open
Abstract
UNLABELLED Targeting interleukin-6 (IL-6) was shown to counteract donor-specific antibody production and antibody-mediated rejection (AMR) activity. It is not known whether, or to what extent, IL-6 antagonism modulates biomarkers indicative of tissue damage (donor-derived cell-free DNA [dd-cfDNA]) and parenchymal inflammation (C-X-C motif chemokine ligand [CXCL] 10). METHODS We report a secondary endpoint analysis of a phase 2 trial of anti-IL-6 antibody clazakizumab in late AMR (ClinicalTrials.gov, NCT03444103). Twenty kidney transplant recipients were randomized to treatment with clazakizumab or placebo over 12 wk (part A), followed by an extension in which all recipients received clazakizumab through week 52 (part B). Biomarkers were evaluated at day 0 and after 12 and 52 wk, respectively. RESULTS Fractional dd-cfDNA (dd-cfDNA[%]) did not significantly change under clazakizumab, with no differences between study arms (clazakizumab versus placebo) at week 12 (1.65% [median; interquartile range: 0.91%-2.78%] versus 0.97% [0.56%-2.30%]; P = 0.25) and no significant decrease from weeks 12 to 52 (1.15% [0.70%-2.38%] versus 1.0% [0.61%-1.70%]; P = 0.25). Similarly, urine CXCL10 was not different between groups at week 12 (55.7 [41.0-91.4] versus 60.2 [48.8-208.7.0] pg/mg creatinine; P = 0.44) and did not change over part B (CXCL10 [pg/mg creatinine]: from 58 [46.3-93.1] to 67.4 [41.5-132.0] pg/mL creatinine; P = 0.95). Similar results were obtained for serum CXCL10. There was no association between biomarker levels and resolution of molecular and morphologic AMR activity. CONCLUSIONS Our results suggest that IL-6 blockade does not significantly affect levels of dd-cfDNA[%] and CXCL10. Subtle responses to this therapeutic principle may be overlooked by early biomarker surveillance.
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15
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Ventura-Aguiar P, Ramirez-Bajo MJ, Rovira J, Bañón-Maneus E, Hierro N, Lazo M, Cuatrecasas M, Garcia-Criado M, Liang N, Swenerton RK, Cofan F, Cucchiari D, Esforzado N, Montagud-Marrahi E, Oppenheimer F, Piñeiro G, Revuelta I, Torregrosa V, Ahmed E, Soboleva K, Kaur N, Zimmermann BG, Al Haj Baddar N, Demko ZP, Escrig C, Tabriziani H, Gauthier P, Billings PR, Amor AJ, Ferrer J, Campistol JM, Diekmann F. Donor-derived Cell-free DNA Shows High Sensitivity for the Diagnosis of Pancreas Graft Rejection in Simultaneous Pancreas-kidney Transplantation. Transplantation 2022; 106:1690-1697. [PMID: 35289777 PMCID: PMC9311279 DOI: 10.1097/tp.0000000000004088] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/29/2021] [Accepted: 01/11/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pancreas graft status in simultaneous pancreas-kidney transplant (SPKTx) is currently assessed by nonspecific biochemical markers, typically amylase or lipase. Identifying a noninvasive biomarker with good sensitivity in detecting early pancreas graft rejection could improve SPKTx management. METHODS Here, we developed a pilot study to explore donor-derived cell-free DNA (dd-cfDNA) performance in predicting biopsy-proven acute rejection (P-BPAR) of the pancreas graft in a cohort of 36 SPKTx recipients with biopsy-matched plasma samples. dd-cfDNA was measured using the Prospera test (Natera, Inc.) and reported both as a fraction of the total cfDNA (fraction; %) and as concentration in the recipient's plasma (quantity; copies/mL). RESULTS In the absence of P-BPAR, dd-cfDNA was significantly higher in samples collected within the first 45 d after SPKTx compared with those measured afterward (median, 1.00% versus 0.30%; median, 128.2 versus 35.3 cp/mL, respectively with both; P = 0.001). In samples obtained beyond day 45, P-BPAR samples presented a significantly higher dd-cfDNA fraction (0.83 versus 0.30%; P = 0.006) and quantity (81.3 versus 35.3 cp/mL; P = 0.001) than stable samples. Incorporating dd-cfDNA quantity along with dd-cfDNA fraction outperformed dd-cfDNA fraction alone to detect active rejection. Notably, when using a quantity cutoff of 70 cp/mL, dd-cfDNA detected P-BPAR with a sensitivity of 85.7% and a specificity of 93.7%, which was more accurate than current biomarkers (area under curve of 0.89 for dd-cfDNA (cp/ml) compared with 0.74 of lipase and 0.46 for amylase). CONCLUSIONS dd-cfDNA measurement through a simple noninvasive blood test could be incorporated into clinical practice to help inform graft management in SPKTx patients.
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Affiliation(s)
- Pedro Ventura-Aguiar
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
| | - Maria Jose Ramirez-Bajo
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Jordi Rovira
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Elisenda Bañón-Maneus
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Natalia Hierro
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Marta Lazo
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Miriam Cuatrecasas
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
| | - M.A. Garcia-Criado
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
| | | | | | - Federic Cofan
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - David Cucchiari
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
| | - Nuria Esforzado
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
| | - Enrique Montagud-Marrahi
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
| | - Federic Oppenheimer
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Gaston Piñeiro
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
| | - Ignacio Revuelta
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Vicens Torregrosa
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
| | - Ebad Ahmed
- Pathology Department, Center for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Karina Soboleva
- Pathology Department, Center for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Navchetan Kaur
- Pathology Department, Center for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Bernhard G. Zimmermann
- Pathology Department, Center for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Nour Al Haj Baddar
- Pathology Department, Center for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Zachary P. Demko
- Pathology Department, Center for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Cesar Escrig
- Pathology Department, Center for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Hossein Tabriziani
- Pathology Department, Center for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Philippe Gauthier
- Pathology Department, Center for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Paul R. Billings
- Pathology Department, Center for Biomedical Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Antonio J. Amor
- Radiology Department, Center for Imaging Diagnosis, Hospital Clínic, Barcelona, Spain
| | - Joana Ferrer
- Endocrinology Department, Hospital Clinic, Barcelona, Spain
| | - Josep M. Campistol
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Fritz Diekmann
- Renal Transplant Unit, Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament, Fundacio Clinic - IDIBAPS, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
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16
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Steggerda JA, Pizzo H, Garrison J, Zhang X, Haas M, Kim IK, Jordan SC, Puliyanda DP. Use of a donor-derived cell-free DNA assay to monitor treatment response in pediatric renal transplant recipients with allograft rejection. Pediatr Transplant 2022; 26:e14258. [PMID: 35340104 DOI: 10.1111/petr.14258] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/09/2022] [Accepted: 02/08/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Detection of donor-derived cell-free DNA (dd-cfDNA) reliably identifies allograft rejection in pediatric and adult kidney transplant (KT) recipients. Here, we evaluate the utility of dd-cfDNA for monitoring response to treatment among pediatric renal transplant recipients suffering graft rejection. METHODS 58 pediatric transplant recipients were enrolled between April 2018 and March 2020 and underwent initial dd-cfDNA testing to monitor for rejection. Allograft biopsy was performed for dd-cfDNA scores >1.0%. Patients with histologically proven rejection formed the study cohort and underwent appropriate treatment. Results of dd-cfDNA, serum creatinine (SCr), biopsy findings, and treatment outcomes were evaluated. Standard statistical analyses were applied. RESULTS Nineteen of 58 (31%) patients had dd-cfDNA score >1.0%, of which 18 (94.7%) had biopsy-proven rejection. Median dd-cfDNA value was 1.90% (interquartile range 1.43%-3.23%), and biopsy results showed 11 patients (61.1%) with antibody-mediated rejection (AMR), 2 patients (11.1%) with T-cell mediated rejection (TCMR), and 5 patients (27.7%) with mixed AMR/TCMR. SCr at time of biopsy was 1.28 ± 1.09 mg/dl. Following treatment, dd-cfDNA scores decreased for all types of rejection but still remained >1.0% in both AMR (1.50% [0.90%-3.10%]) and mixed (1.40% [0.95%-4.15%]) groups. Repeat dd-cfDNA values were <1.0% for patients with TCMR (0.20%-0.28%). SCr showed minimal change from pre-treatment levels regardless of rejection subtype. CONCLUSIONS Patients with TCMR may be reliably followed by dd-cfDNA; however, it remains unclear whether persistently elevated dd-cfDNA levels in AMR is a reflection of ongoing subclinical rejection or an inherent limitation of the assay's utility.
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Affiliation(s)
- Justin A Steggerda
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Helen Pizzo
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Jonathan Garrison
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Xiaohai Zhang
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Mark Haas
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Irene K Kim
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Stanley C Jordan
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
| | - Dechu P Puliyanda
- Cedars Sinai Medical Center, Pediatric Nephrology, Los Angeles, California, USA
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17
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Bu L, Gupta G, Pai A, Anand S, Stites E, Moinuddin I, Bowers V, Jain P, Axelrod DA, Weir MR, Wolf-Doty TK, Zeng J, Tian W, Qu K, Woodward R, Dholakia S, De Golovine A, Bromberg JS, Murad H, Alhamad T. Validation and clinical outcome in assessing donor-derived cell-free DNA monitoring insights of kidney allografts with longitudinal surveillance (ADMIRAL) study. Kidney Int 2021; 101:793-803. [PMID: 34953773 DOI: 10.1016/j.kint.2021.11.034] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/04/2021] [Accepted: 11/22/2021] [Indexed: 12/18/2022]
Abstract
The use of routine monitoring of donor-derived cell-free DNA (dd-cfDNA) after kidney transplant may allow clinicians to identify subclinical allograft injury and intervene prior to development of clinically evident graft injury. To evaluate this, data from 1092 kidney transplant recipients monitored for dd-cfDNA over a three year period was analyzed to assess the association of dd-cfDNA with histologic evidence of allograft rejection. Elevation of dd-cfDNA (0.5% or more) was significantly correlated with clinical and subclinical allograft rejection. dd-cfDNA values of 0.5% or more were associated with a nearly three-fold increase in risk development of de novo donor specific antibodies (hazard ratio 2.71) and were determined to be elevated a median of 91 days (inter quartile range of 30-125 days) ahead of donor specific antibody identification. Persistently elevated dd-cfDNA (more than one result above the 0.5% threshold) predicted over a 25% decline in the estimated glomerular filtration rate over three years (hazard ratio 1.97). Therefore, routine monitoring of dd-cfDNA allowed early identification of clinically important graft injury. Biomarker monitoring complemented histology and traditional laboratory surveillance strategies as a prognostic marker and risk-stratification tool post-transplant. Thus, persistently low dd-cfDNA levels may accurately identify allograft quiescence, or absence of injury, paving the way for personalization of immunosuppression trials.
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Affiliation(s)
| | | | - Akshta Pai
- University of Texas Health Science Center, Memorial Hermann Hospital
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18
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Akalin E, Weir MR, Bunnapradist S, Brennan DC, Delos Santos R, Langone A, Djamali A, Xu H, Jin X, Dholakia S, Woodward RN, Bromberg JS. Clinical Validation of an Immune Quiescence Gene Expression Signature in Kidney Transplantation. KIDNEY360 2021; 2:1998-2009. [PMID: 35419538 PMCID: PMC8986041 DOI: 10.34067/kid.0005062021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/27/2021] [Indexed: 02/07/2023]
Abstract
Background Despite advances in immune suppression, kidney allograft rejection and other injuries remain a significant clinical concern, particularly with regards to long-term allograft survival. Evaluation of immune activity can provide information about rejection status and help guide interventions to extend allograft life. Here, we describe the validation of a blood gene expression classifier developed to differentiate immune quiescence from both T cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR). Methods A five-gene classifier (DCAF12, MARCH8, FLT3, IL1R2, and PDCD1) was developed on 56 peripheral blood samples and validated on two sample sets independent of the training cohort. The primary validation set comprised 98 quiescence samples and 18 rejection samples: seven TCMR, ten ABMR, and one mixed rejection. The second validation set included eight quiescence and 11 rejection samples: seven TCMR, two ABMR, and two mixed rejection. AlloSure donor-derived cell-free DNA (dd-cfDNA) was also evaluated. Results AlloMap Kidney classifier scores in the primary validation set differed significantly between quiescence (median, 9.49; IQR, 7.68-11.53) and rejection (median, 13.09; IQR, 11.25-15.28), with P<0.001. In the second validation set, the cohorts were statistically different (P=0.03) and the medians were similar to the primary validation set. The AUC for discriminating rejection from quiescence was 0.786 for the primary validation and 0.800 for the second validation. AlloMap Kidney results were not significantly correlated with AlloSure, although both were elevated in rejection. The ability to discriminate rejection from quiescence was improved when AlloSure and AlloMap Kidney were used together (AUC, 0.894). Conclusion Validation of AlloMap Kidney demonstrated the ability to differentiate between rejection and immune quiescence using a range of scores. The diagnostic performance suggests that assessment of the mechanisms of immunologic activity is complementary to allograft injury information derived from AlloSure dd-cfDNA. Together, these biomarkers offer a more comprehensive assessment of allograft health and immune quiescence.
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Affiliation(s)
- Enver Akalin
- Division of Nephrology, Kidney Transplant Program, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Matthew R. Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Suphamai Bunnapradist
- Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Daniel C. Brennan
- Comprehensive Transplant Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rowena Delos Santos
- Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri
| | - Anthony Langone
- Vanderbilt University Medical Center, Medical Specialties Clinic, Veteran Affairs Hospital Renal Transplant Program, Nashville, Tennessee
| | - Arjang Djamali
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Hua Xu
- Research and Development, CareDx, Brisbane, California
| | - Xia Jin
- Research and Development, CareDx, Brisbane, California
| | - Sham Dholakia
- Medical Affairs, CareDx, South San Francisco, California
| | | | - Jonathan S. Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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19
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Correlation of Donor-Derived Cell-free DNA with Histology and Molecular Diagnoses of Kidney Transplant Biopsies. Transplantation 2021; 106:1061-1070. [PMID: 34075006 DOI: 10.1097/tp.0000000000003838] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Circulating donor-derived cell free DNA (cfDNA), a minimally invasive diagnostic tool for kidney transplant rejection, was validated using traditional histology. The Molecular Microscope (MMDx) tissue gene expression platform may provide increased precision to traditional histology. METHODS In this single-center prospective study of 208 biopsies (median=5.8 months) post-transplant, we report on the calibration of cfDNA with simultaneous biopsy assessments using MMDx and histology by Area under the curve (AUC) analyses for optimal criterion, as well as for, previously published cfDNA cut-offs ≤0.21% to 'rule-out' rejection and ≥1% to 'rule-in' rejection. RESULTS There were significant discrepancies between histology and MMDx, with MMDx identifying more antibody-mediated rejection (65; 31%) than histology (43; 21%); the opposite was true for T-cell mediated rejection [TCMR; histology: 27 (13%) vs MMDx: 13 (6%)]. Most of the TCMR discrepancies were seen for histologic borderline/1A TCMR. AUC Curves for cfDNA and prediction of rejection were slightly better with MMDx (AUC=0.80; 95%CI: 0.74-0.86) vs. histology (AUC=0.75; 95%CI: 0.69-0.81). A cfDNA≤0.21% had similar sensitivity (~91%) to 'rule-out' rejection by histology and MMDx. Specificity was slightly higher with MMDx (92%) compared with histology (85%) to 'rule-in' rejection using cfDNA criterion≥1%. Strong positive quantitative correlations were observed between cfDNA scores and molecular acute kidney injury (AKI) for both 'rejection' and 'nonrejection' biopsies. CONCLUSIONS Molecular diagnostics using tissue gene expression and blood-based donor-derived cell-free DNA may add precision to some cases of traditional histology. The positive correlation of cfDNA with molecular AKI suggests a dose-dependent association with tissue injury irrespective of rejection characteristics.
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