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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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Jiménez-Coll V, El Kaaoui El Band J, Llorente S, González-López R, Fernández-González M, Martínez-Banaclocha H, Galián JA, Botella C, Moya-Quiles MR, Minguela A, Legaz I, Muro M. All That Glitters in cfDNA Analysis Is Not Gold or Its Utility Is Completely Established Due to Graft Damage: A Critical Review in the Field of Transplantation. Diagnostics (Basel) 2023; 13:1982. [PMID: 37370877 DOI: 10.3390/diagnostics13121982] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/24/2023] [Accepted: 06/03/2023] [Indexed: 06/29/2023] Open
Abstract
In kidney transplantation, a biopsy is currently the gold standard for monitoring the transplanted organ. However, this is far from an ideal screening method given its invasive nature and the discomfort it can cause the patient. Large-scale studies in renal transplantation show that approximately 1% of biopsies generate major complications, with a risk of macroscopic hematuria greater than 3.5%. It would not be until 2011 that a method to detect donor-derived cell-free DNA (dd-cfDNA) employing digital PCR was devised based on analyzing the differences in SNPs between the donor and recipient. In addition, since the initial validation studies were carried out at the specific moments in which rejection was suspected, there is still not a good understanding of how dd-cfDNA levels naturally evolve post-transplant. In addition, various factors, both in the recipient and the donor, can influence dd-cfDNA levels and cause increases in the levels of dd-cfDNA themselves without suspicion of rejection. All that glitters in this technology is not gold; therefore, in this article, we discuss the current state of clinical studies, the benefits, and disadvantages.
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Affiliation(s)
- Victor Jiménez-Coll
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Jaouad El Kaaoui El Band
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Santiago Llorente
- Nephrology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Rosana González-López
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Marina Fernández-González
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Helios Martínez-Banaclocha
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - José Antonio Galián
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Carmen Botella
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - María Rosa Moya-Quiles
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Alfredo Minguela
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Isabel Legaz
- Department of Legal and Forensic Medicine, Biomedical Research Institute of Murcia (IMIB), Faculty of Medicine, Regional Campus of International Excellence "Campus Mare Nostrum", University of Murcia, 30100 Murcia, Spain
| | - Manuel Muro
- Immunology Service, University Clinical Hospital Virgen de la Arrixaca, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
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Donor-Derived Cell-free DNA for Personalized Immunosuppression in Renal Transplantation. Ther Drug Monit 2023; 45:20-25. [PMID: 36127770 DOI: 10.1097/ftd.0000000000001023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/13/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The long-term outcomes of solid organ transplantation remain suboptimal. Therefore, appropriate biomarkers are needed in addition to immunosuppressive drugs and other traditional approaches for graft monitoring to achieve personalized immunosuppression and reduce premature graft loss. METHODS Donor-derived cell-free DNA (dd-cfDNA) is a minimally invasive biomarker of cell death due to graft injury. It can be quantified using droplet digital polymerase chain reaction and next-generation sequencing. Fractional dd-cfDNA determination can be affected by changes in recipient cfDNA, such as those caused by leukopenia or infection, leading to false-positive or false-negative results, respectively. Absolute quantification of dd-cfDNA helps in overcoming this limitation. RESULTS Overall, there is sufficient evidence of the clinical validity of dd-cfDNA. It detects rejection episodes early at an actionable stage and reflects the severity of graft injury without being rejection-specific. Owing to its high negative predictive value, dd-cfDNA is very useful for ruling out graft injury. Dd-cfDNA complements histological findings and can help in avoiding unnecessary biopsies. It indicates a response to rejection treatment and detects underimmunosuppression. CONCLUSIONS Monitoring changes in dd-cfDNA over time may be helpful in adapting immunosuppression to prevent graft rejection. Moreover, serial dd-cfDNA determination may increase the effectiveness of transplant recipient surveillance and facilitate personalized immunosuppression when combined with other relevant clinical and diagnostic findings.
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Oellerich M, Budde K, Osmanodja B, Bornemann-Kolatzki K, Beck J, Schütz E, Walson PD. Donor-derived cell-free DNA as a diagnostic tool in transplantation. Front Genet 2022; 13:1031894. [PMID: 36339004 PMCID: PMC9634115 DOI: 10.3389/fgene.2022.1031894] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/11/2022] [Indexed: 11/22/2022] Open
Abstract
There is a need to improve personalized immunosuppression in organ transplantation to reduce premature graft loss. Biomarkers are needed to better detect rejection, asymptomatic graft injury, and under-immunosuppression. Assessment of minimal necessary exposure to guide tapering and prevent immune activation is also important. There is robust clinical evidence from a large number of published studies supporting the role of dd-cfDNA for monitoring graft integrity and detection or exclusion of rejection. Dd-cfDNA indicates graft cell death without being rejection specific. It can be determined in plasma through droplet digital PCR using preselected SNPs or next generation sequencing. Changes in recipient cfDNA (e.g., by infection) can affect the results of dd-cfDNA fractional determination. This limitation can be overcome using absolute dd-cfDNA quantification. The combination of fractional and absolute determination including total cfDNA is recommended for meaningful interpretation of the results. The value proposition for the patient includes earlier transplant injury detection and intervention, less full blown rejection risk, an alternative to invasive biopsies, and personalized immunosuppression with potential for improved long-term outcome. Transplant physicians benefit from better immunosuppressive guidance and having an alternative when biopsies are refused or contraindicated. Further advantages are improved biopsy interpretation, less trial and error changes in immunosuppression, and less time dealing with complications. The laboratory medicine specialist can provide more effective services. Hospital management and insurance companies could benefit from more cost-effective surveillance of transplant recipients. Potential cost savings would result from fewer biopsies as a result of the tests’ high negative predictive value, fewer re-transplantations, and less organ failure with return to dialysis. A pathway to implementation and metrics is suggested to measure the effectiveness of dd-cfDNA testing.
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Affiliation(s)
- Michael Oellerich
- Department of Clinical Pharmacology, University Medical Center Göttingen, Göttingen, Germany
- *Correspondence: Michael Oellerich,
| | - Klemens Budde
- Department of Nephrology and Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bilgin Osmanodja
- Department of Nephrology and Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | | | - Julia Beck
- Chronix Biomedical GmbH, Göttingen, Germany
| | | | - Philip D. Walson
- Department of Clinical Pharmacology, University Medical Center Göttingen, Göttingen, Germany
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Keller MB, Meda R, Fu S, Yu K, Jang MK, Charya A, Berry GJ, Marboe CC, Kong H, Luikart H, Ponor IL, Shah PD, Khush KK, Nathan SD, Agbor‐Enoh S. Comparison of donor-derived cell-free DNA between single versus double lung transplant recipients. Am J Transplant 2022; 22:2451-2457. [PMID: 35322546 PMCID: PMC9508279 DOI: 10.1111/ajt.17039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/02/2022] [Accepted: 03/17/2022] [Indexed: 01/25/2023]
Abstract
Plasma donor-derived cell-free DNA (dd-cfDNA) is a sensitive biomarker for the diagnosis of acute rejection in lung transplant recipients; however, differences in dd-cfDNA levels between single and double lung transplant remains unknown. We performed an observational analysis that included 221 patients from two prospective cohort studies who had serial measurements of plasma dd-cfDNA at the time of bronchoscopy and pulmonary function testing, and compared dd-cfDNA between single and double lung transplant recipients across a range of disease states. Levels of dd-cfDNA were lower for single vs. double lung transplant in stable controls (median [IQR]: 0.15% [0.07, 0.44] vs. 0.46% [0.23, 0.74], p < .01) and acute rejection (1.06% [0.75, 2.32] vs. 1.78% [1.18, 5.73], p = .05). Doubling dd-cfDNA for single lung transplant to account for differences in lung mass eliminated this difference. The area under the receiver operating curve (AUC) for the detection of acute rejection was 0.89 and 0.86 for single and double lung transplant, respectively. The optimal dd-cfDNA threshold for the detection of acute rejection was 0.54% in single lung and 1.1% in double lung transplant. In conclusion, accounting for differences in dd-cfDNA in single versus double lung transplant is key for the interpretation of dd-cfDNA testing in research and clinical settings.
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Affiliation(s)
- Michael B. Keller
- Genomic Research Alliance for Transplantation (GRAfT)BethesdaMarylandUSA,Laboratory of Applied Precision Omics (APO)National Heart, Lung and Blood InstituteBethesdaMarylandUSA,Division of Pulmonary and Critical Care MedicineThe Johns Hopkins School of MedicineBaltimoreMarylandUSA
| | - Rohan Meda
- Laboratory of Applied Precision Omics (APO)National Heart, Lung and Blood InstituteBethesdaMarylandUSA
| | - Sheng Fu
- National Cancer InstituteRockvilleMarylandUSA
| | - Kai Yu
- National Cancer InstituteRockvilleMarylandUSA
| | - Moon Kyoo Jang
- Genomic Research Alliance for Transplantation (GRAfT)BethesdaMarylandUSA,Laboratory of Applied Precision Omics (APO)National Heart, Lung and Blood InstituteBethesdaMarylandUSA
| | - Ananth Charya
- University of Maryland Medical CenterBaltimoreMarylandUSA
| | - Gerald J. Berry
- Genomic Research Alliance for Transplantation (GRAfT)BethesdaMarylandUSA,Stanford University School of MedicineStanfordCaliforniaUSA
| | - Charles C. Marboe
- Genomic Research Alliance for Transplantation (GRAfT)BethesdaMarylandUSA,Department of Pathology and Cell BiologyVagelos College of Physicians and Surgeons of Columbia UniversityNew YorkNew YorkUSA
| | - Hyesik Kong
- Genomic Research Alliance for Transplantation (GRAfT)BethesdaMarylandUSA,Laboratory of Applied Precision Omics (APO)National Heart, Lung and Blood InstituteBethesdaMarylandUSA
| | - Helen Luikart
- Stanford University School of MedicineStanfordCaliforniaUSA
| | - Ileana L. Ponor
- Department of MedicineJohns Hopkins Bayview Medical CenterBaltimoreMarylandUSA
| | - Pali D. Shah
- Genomic Research Alliance for Transplantation (GRAfT)BethesdaMarylandUSA,Division of Pulmonary and Critical Care MedicineThe Johns Hopkins School of MedicineBaltimoreMarylandUSA
| | - Kiran K. Khush
- Stanford University School of MedicineStanfordCaliforniaUSA
| | - Steven D. Nathan
- Genomic Research Alliance for Transplantation (GRAfT)BethesdaMarylandUSA,Inova Fairfax HospitalFairfaxVAUSA
| | - Sean Agbor‐Enoh
- Genomic Research Alliance for Transplantation (GRAfT)BethesdaMarylandUSA,Laboratory of Applied Precision Omics (APO)National Heart, Lung and Blood InstituteBethesdaMarylandUSA,Division of Pulmonary and Critical Care MedicineThe Johns Hopkins School of MedicineBaltimoreMarylandUSA
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