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Zhu V, Perry LA, Plummer M, Segal R, Smith J, Liu Z. Diagnostic accuracy of brain natriuretic peptide and N-terminal-pro brain natriuretic peptide to detect complications of cardiac transplantation in adults: A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100774. [PMID: 37433240 DOI: 10.1016/j.trre.2023.100774] [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: 04/17/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND We aimed to evaluate the utility of BNP and NT-proBNP in identifying adverse recipient outcomes following cardiac transplantation. METHODS We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library from inception to February 2023. We included studies reporting associations between BNP or NT-proBNP and adverse outcomes following cardiac transplantation in adults. We calculated standardised mean differences (SMD) with 95% confidence intervals (CI); or confusion matrices with sensitivities and specificities. Where meta-analysis was inappropriate, studies were analysed descriptively. RESULTS Thirty-two studies involving 2,297 cardiac transplantation recipients were included. We report no significant association between BNP or NT-proBNP and significant acute cellular rejection of grade 3A or higher (SMD 0.40, 95% CI -0.06-0.86) as defined by the latest 2004 International Society for Heart and Lung Transplantation Guidelines. We also report no strong associations between BNP or NT-proBNP and cardiac allograft vasculopathy or antibody mediated rejection. CONCLUSION In isolation, serum BNP and NT-proBNP lack sufficient sensitivity and specificity to reliably predict adverse outcomes following cardiac transplantation.
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Affiliation(s)
- Victor Zhu
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, Australia; Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia.
| | - Luke A Perry
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, Australia; Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Mark Plummer
- Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia; Department of Intensive Care Medicine, Royal Adelaide Hospital, Adelaide, Australia
| | - Reny Segal
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, Australia; Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Julian Smith
- Department of Surgery, Monash University, Clayton, Australia
| | - Zhengyang Liu
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, Australia; Department of Critical Care, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
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2
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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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3
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Deng MC. The evolution of patient-specific precision biomarkers to guide personalized heart-transplant care. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2021; 6:51-63. [PMID: 33768160 DOI: 10.1080/23808993.2021.1840273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Introduction In parallel to the clinical maturation of heart transplantation over the last 50 years, rejection testing has been revolutionized within the systems biology paradigm triggered by the Human Genome Project. Areas Covered We have co-developed the first FDA-cleared diagnostic and prognostic leukocyte gene expression profiling biomarker test in transplantation medicine that gained international evidence-based medicine guideline acceptance to rule out moderate/severe acute cellular cardiac allograft rejection without invasive endomyocardial biopsies. This work prompted molecular re-classification of intragraft biology, culminating in the identification of a pattern of intragraft myocyte injury, in addition to acute cellular rejection and antibody-mediated rejection. This insight stimulated research into non-invasive detection of myocardial allograft injury. The addition of a donor-organ specific myocardial injury marker based on donor-derived cell-free DNA further strengthens the non-invasive monitoring concept, combining the clinical use of two complementary non-invasive blood-based measures, host immune activity-related risk of acute rejection as well as cardiac allograft injury. Expert Opinion This novel complementary non-invasive heart transplant monitoring strategy based on leukocyte gene expression profiling and donor-derived cell-free DNA that incorporates longitudinal variability measures provides an exciting novel algorithm of heart transplant allograft monitoring. This algorithm's clinical utility will need to be tested in an appropriately designed randomized clinical trial which is in preparation.
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Affiliation(s)
- Mario C Deng
- Advanced Heart Failure/Mechanical Support/Heart Transplant, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, 100 Medical Plaza Drive, Suite 630, Los Angeles, CA 90095
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4
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Shannon CP, Hollander Z, Dai DLY, Chen V, Assadian S, Lam KK, McManus JE, Zarzycki M, Kim Y, Kim JYV, Balshaw R, Gidlöf O, Öhman J, Smith JG, Toma M, Ignaszewski A, Davies RA, Delgado D, Haddad H, Isaac D, Kim D, Mui A, Rajda M, West L, White M, Zieroth S, Tebbutt SJ, Keown PA, McMaster WR, Ng RT, McManus BM. HEARTBiT: A Transcriptomic Signature for Excluding Acute Cellular Rejection in Adult Heart Allograft Patients. Can J Cardiol 2019; 36:1217-1227. [PMID: 32553820 DOI: 10.1016/j.cjca.2019.11.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/30/2019] [Accepted: 11/07/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Nine mRNA transcripts associated with acute cellular rejection (ACR) in previous microarray studies were ported to the clinically amenable NanoString nCounter platform. Here we report the diagnostic performance of the resulting blood test to exclude ACR in heart allograft recipients: HEARTBiT. METHODS Blood samples for transcriptomic profiling were collected during routine post-transplantation monitoring in 8 Canadian transplant centres participating in the Biomarkers in Transplantation initiative, a large (n = 1622) prospective observational study conducted between 2009 and 2014. All adult cardiac transplant patients were invited to participate (median age = 56 [17 to 71]). The reference standard for rejection status was histopathology grading of tissue from endomyocardial biopsy (EMB). All locally graded ISHLT ≥ 2R rejection samples were selected for analysis (n = 36). ISHLT 1R (n = 38) and 0R (n = 86) samples were randomly selected to create a cohort approximately matched for site, age, sex, and days post-transplantation, with a focus on early time points (median days post-transplant = 42 [7 to 506]). RESULTS ISHLT ≥ 2R rejection was confirmed by EMB in 18 and excluded in 92 samples in the test set. HEARTBiT achieved 47% specificity (95% confidence interval [CI], 36%-57%) given ≥ 90% sensitivity, with a corresponding area under the receiver operating characteristic curve of 0.69 (95% CI, 0.56-0.81). CONCLUSIONS HEARTBiT's diagnostic performance compares favourably to the only currently approved minimally invasive diagnostic test to rule out ACR, AlloMap (CareDx, Brisbane, CA) and may be used to inform care decisions in the first 2 months post-transplantation, when AlloMap is not approved, and most ACR episodes occur.
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Affiliation(s)
- Casey P Shannon
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada.
| | - Zsuzsanna Hollander
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Darlene L Y Dai
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Virginia Chen
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Sara Assadian
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Karen K Lam
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet E McManus
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada
| | - Marek Zarzycki
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - YoungWoong Kim
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ji-Young V Kim
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Balshaw
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Olof Gidlöf
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jenny Öhman
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - J Gustav Smith
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Mustafa Toma
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew Ignaszewski
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ross A Davies
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Diego Delgado
- University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Haissam Haddad
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Debra Isaac
- Department of Medicine, University of Alberta, Calgary, Aberta, Canada
| | - Daniel Kim
- Department of Medicine, University of Alberta, Calgary, Aberta, Canada
| | - Alice Mui
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Miroslaw Rajda
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lori West
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Michel White
- Institut de Cardiologie de Montréal, Montréal, Québec, Canada
| | - Shelley Zieroth
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Scott J Tebbutt
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul A Keown
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - W Robert McMaster
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raymond T Ng
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Department of Computer Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bruce M McManus
- Prevention of Organ Failure (PROOF) Centre of Excellence, Vancouver, British Columbia, Canada; Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada.
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Khush KK, Patel J, Pinney S, Kao A, Alharethi R, DePasquale E, Ewald G, Berman P, Kanwar M, Hiller D, Yee JP, Woodward RN, Hall S, Kobashigawa J. Noninvasive detection of graft injury after heart transplant using donor-derived cell-free DNA: A prospective multicenter study. Am J Transplant 2019; 19:2889-2899. [PMID: 30835940 PMCID: PMC6790566 DOI: 10.1111/ajt.15339] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 02/01/2019] [Accepted: 02/24/2019] [Indexed: 01/25/2023]
Abstract
Standardized donor-derived cell-free DNA (dd-cfDNA) testing has been introduced into clinical use to monitor kidney transplant recipients for rejection. This report describes the performance of this dd-cfDNA assay to detect allograft rejection in samples from heart transplant (HT) recipients undergoing surveillance monitoring across the United States. Venous blood was longitudinally sampled from 740 HT recipients from 26 centers and in a single-center cohort of 33 patients at high risk for antibody-mediated rejection (AMR). Plasma dd-cfDNA was quantified by using targeted amplification and sequencing of a single nucleotide polymorphism panel. The dd-cfDNA levels were correlated to paired events of biopsy-based diagnosis of rejection. The median dd-cfDNA was 0.07% in reference HT recipients (2164 samples) and 0.17% in samples classified as acute rejection (35 samples; P = .005). At a 0.2% threshold, dd-cfDNA had a 44% sensitivity to detect rejection and a 97% negative predictive value. In the cohort at risk for AMR (11 samples), dd-cfDNA levels were elevated 3-fold in AMR compared with patients without AMR (99 samples, P = .004). The standardized dd-cfDNA test identified acute rejection in samples from a broad population of HT recipients. The reported test performance characteristics will guide the next stage of clinical utility studies of the dd-cfDNA assay.
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Affiliation(s)
- Kiran K. Khush
- Division of Cardiovascular MedicineStanford UniversityStanfordCalifornia
| | - Jignesh Patel
- Cedars‐Sinai Smidt Heart InstituteLos AngelesCalifornia
| | | | - Andrew Kao
- St. Luke's Hospital Mid America Heart InstituteKansas CityMissouri
| | | | | | - Gregory Ewald
- Washington University School of MedicineSaint LouisMissouri
| | | | | | - David Hiller
- Research and DevelopmentCareDxBrisbaneCalifornia
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6
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Xin A, Lee MGY, Hu Y, Ignjatovic V, Shi WY, Shipp A, Praporski S, Kallies A, Weintraub RG, Monagle PT, Smyth GK, Konstantinov IE. Identifying low-grade cellular rejection after heart transplantation in children by using gene expression profiling. Physiol Genomics 2017; 50:190-196. [PMID: 29341866 DOI: 10.1152/physiolgenomics.00046.2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Endomyocardial biopsy (EMB) remains the gold standard for detecting rejection after heart transplantation but is costly and invasive. This study aims to distinguish no rejection (0R) from low-grade rejection (1R/2R) after heart transplantation in children by using global gene expression profiling in blood. A total of 106 blood samples with corresponding EMB from 18 children who underwent heart transplantation from 2011 to 2014 were analyzed (18 baseline/pretransplantation samples, 88 EMB samples). Corresponding rejection grades for each blood sample were 0R in 39% (34/88), 1R in 51% (45/88), and 2R in 10% (9/88). mRNA from each sample was sequenced. Differential expression analysis was performed at the gene level. A k-nearest neighbor (kNN) analysis was applied to the most differentially expressed (DE) genes to identify rejection after transplantation. Mean age at transplantation was 10.0 ± 5.4 yr. Expression of B cell and T cell receptor sequences was used to measure the effect of posttransplantation immunosuppression. Follow-up samples had lower levels of immunoglobulin gene families compared with pretransplantation ( P < 3E-5) (lower numbers of activated B cells). T cell receptor alpha and beta gene families had decreased expression in 0R samples compared with pretransplantation ( P < 4E-5) but recovered to near baseline levels in 1R/2R samples. kNN using the most DE gene (MKS1) and k = 9 nearest neighbors correctly identified 83% (73/88) of 1R/2R compared with 0R by leave-one-out cross validation. Using a genomic approach we can distinguish low-grade cellular allograft rejection (1R/2R) from no rejection (0R) after heart transplantation in children despite a wide age range.
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Affiliation(s)
- Annie Xin
- Department of Cardiac Surgery, The Royal Children's Hospital , Melbourne , Australia.,Department of Paediatrics, University of Melbourne , Melbourne , Australia
| | - Melissa G Y Lee
- Department of Cardiac Surgery, The Royal Children's Hospital , Melbourne , Australia.,Department of Paediatrics, University of Melbourne , Melbourne , Australia.,Heart Research Group, Murdoch Children's Research Institute , Melbourne , Australia
| | - Yifang Hu
- Bioinformatics Division, The Walter and Eliza Hall Institute of Medical Research , Melbourne , Australia
| | - Vera Ignjatovic
- Department of Paediatrics, University of Melbourne , Melbourne , Australia.,Haematology Research Group, Murdoch Children's Research Institute
| | - William Y Shi
- Department of Cardiac Surgery, The Royal Children's Hospital , Melbourne , Australia.,Department of Paediatrics, University of Melbourne , Melbourne , Australia.,Heart Research Group, Murdoch Children's Research Institute , Melbourne , Australia
| | - Anne Shipp
- Department of Cardiology, The Royal Children's Hospital , Melbourne , Australia
| | - Slavica Praporski
- Heart Research Group, Murdoch Children's Research Institute , Melbourne , Australia
| | - Axel Kallies
- Molecular Immunology Division, The Walter and Eliza Hall Institute of Medical Research , Melbourne , Australia.,Department of Medical Biology, University of Melbourne , Melbourne , Australia
| | - Robert G Weintraub
- Department of Paediatrics, University of Melbourne , Melbourne , Australia.,Heart Research Group, Murdoch Children's Research Institute , Melbourne , Australia.,Department of Cardiology, The Royal Children's Hospital , Melbourne , Australia
| | - Paul T Monagle
- Department of Paediatrics, University of Melbourne , Melbourne , Australia.,Haematology Research Group, Murdoch Children's Research Institute
| | - Gordon K Smyth
- Bioinformatics Division, The Walter and Eliza Hall Institute of Medical Research , Melbourne , Australia.,School of Mathematics and Statistics, University of Melbourne , Melbourne , Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, The Royal Children's Hospital , Melbourne , Australia.,Department of Paediatrics, University of Melbourne , Melbourne , Australia.,Heart Research Group, Murdoch Children's Research Institute , Melbourne , Australia
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7
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Fitzsimons S, Evans J, Parameshwar J, Pettit SJ. Utility of troponin assays for exclusion of acute cellular rejection after heart transplantation: A systematic review. J Heart Lung Transplant 2017; 37:631-638. [PMID: 29426716 DOI: 10.1016/j.healun.2017.12.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/06/2017] [Accepted: 12/05/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Acute cellular rejection (ACR) is a common complication in the first year after heart transplantation (HT). Routine surveillance for ACR is undertaken by endomyocardial biopsy (EMB). Measurement of cardiac troponins (cTn) in serum is an established diagnostic test of cardiac myocyte injury. This systematic review aimed to determine whether cTn measurement could be used to diagnose or exclude ACR. METHODS PubMed, Google Scholar and the JHLT archive were searched for studies reporting the result of a cTn assay and a paired surveillance EMB. Significant ACR was defined as International Society for Heart and Lung Transplantataion (ISHLT) Grade ≥3a/≥2R. Considerable heterogeneity between studies precluded quantitative meta-analysis. Individual study sensitivity and specificity data were examined and used to construct a pooled hierarchical summary receiver-operator characteristic (ROC) curve. RESULTS Twelve studies including 993 patients and 3,803 EMBs, of which 3,729 were paired with cTn levels, had adequate data available for inclusion. The overall rate of significant ACR was 12%. There was wide variation in diagnostic performance. cTn assays demonstrated sensitivity of 8% to 100% and specificity of 13% to 88% for detection of ACR. The positive predictive value (PPV) was low but the negative predictive value (NPV) was relatively high (79% to 100%). High-sensitivity cTn assays had greater sensitivity and NPV than conventional cTn assays for detection of ACR (sensitivity: 82% to 100% vs 8% to 77%; NPV: 97% to 100% vs 81% to 95%, respectively). CONCLUSIONS cTn assays do not have sufficient specificity to diagnose ACR in place of EMB. However, hs-cTn assays may have sufficient sensitivity and negative predictive value to exclude ACR and limit the need for surveillance EMB. Further research is required to assess this strategy.
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Affiliation(s)
- Sarah Fitzsimons
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - Jonathan Evans
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jayan Parameshwar
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen J Pettit
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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8
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Mavrogeni SI, Athanasopoulos G, Gouziouta A, Leontiadis E, Adamopoulos S, Kolovou G. Cardiac transplantation: towards a new noninvasive approach of cardiac allograft rejection. Expert Rev Cardiovasc Ther 2017; 15:307-313. [DOI: 10.1080/14779072.2017.1307734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | | | - Aggeliki Gouziouta
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | | | | | - Genovefa Kolovou
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
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9
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Abstract
Over the last >20 years, we have co-developed the rationale for the first diagnostic and prognostic leukocyte gene expression profiling (GEP) biomarker test in transplantation medicine that gained US-FDA-regulatory clearance and international evidence-based medicine guideline acceptance to rule out moderate/severe acute cellular cardiac allograft rejection without invasive endomyocardial biopsies (EMB). Based on this test, a non-invasive clinical algorithm was implemented since 2005. After clinical implementation, this GEP-based monitoring in direct comparison with an EMB-based strategy was non-inferior with respect to detection of clinical rejection, defined as new onset allograft dysfunction with/without histology of ACR, re-transplantation or death, and at the same time improved patient satisfaction. Subsequently, we demonstrated the test's capacity when used as serial monitoring tool to predict these clinical rejection events. In this Personal Viewpoint article, I will discuss the various decision-making branching points that were made in the AlloMap biomarker test development to inform future genomic biomarker test development projects.
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Affiliation(s)
- Mario C Deng
- Advanced Heart Failure/Mechanical Support/Heart Transplant, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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10
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Detecting Cardiac Allograft Rejection in the Era of Personalized Medicine: a Review of Current Genomic Surveillance Techniques. CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0125-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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11
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Mathews L, Lott JM, Isse K, Lesniak A, Landsittel D, Demetris AJ, Sun Y, Mercer DF, Webber SA, Zeevi A, Fischer RT, Feingold B, Turnquist HR. Elevated ST2 Distinguishes Incidences of Pediatric Heart and Small Bowel Transplant Rejection. Am J Transplant 2016; 16:938-50. [PMID: 26663613 PMCID: PMC5078748 DOI: 10.1111/ajt.13542] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 08/27/2015] [Accepted: 09/19/2015] [Indexed: 01/25/2023]
Abstract
Elevated serum soluble (s) suppressor of tumorigenicity-2 is observed during cardiovascular and inflammatory bowel diseases. To ascertain whether modulated ST2 levels signify heart (HTx) or small bowel transplant (SBTx) rejection, we quantified sST2 in serially obtained pediatric HTx (n = 41) and SBTx recipient (n = 18) sera. At times of biopsy-diagnosed HTx rejection (cellular and/or antibody-mediated), serum sST2 was elevated compared to rejection-free time points (1714 ± 329 vs. 546.5 ± 141.6 pg/mL; p = 0.0002). SBTx recipients also displayed increased serum sST2 during incidences of rejection (7536 ± 1561 vs. 2662 ± 543.8 pg/mL; p = 0.0347). Receiver operator characteristic (ROC) analysis showed that serum sST2 > 600 pg/mL could discriminate time points of HTx rejection and nonrejection (area under the curve [AUC] = 0.724 ± 0.053; p = 0.0003). ROC analysis of SBTx measures revealed a similar discriminative capacity (AUC = 0.6921 ± 0.0820; p = 0.0349). Quantitative evaluation of both HTx and SBTx biopsies revealed that rejection significantly increased allograft ST2 expression. Pathway and Network Analysis of biopsy data pinpointed ST2 in the dominant pathway modulated by rejection and predicted tumor necrosis factor-α and IL-1β as upstream activators. In total, our data indicate that alloimmune-associated pro-inflammatory cytokines increase ST2 during rejection. They also demonstrate that routine serum sST2 quantification, potentially combined with other biomarkers, should be investigated further to aid in the noninvasive diagnosis of rejection.
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Affiliation(s)
- L.R. Mathews
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA,Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - J. M. Lott
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - K. Isse
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA,Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - A. Lesniak
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA,Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - D. Landsittel
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - A. J. Demetris
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA,Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Y. Sun
- Department of Pediatric Gastroenterology, University of Nebraska Medical Center, Omaha, NE
| | - D. F. Mercer
- Department of Pediatric Gastroenterology, University of Nebraska Medical Center, Omaha, NE
| | - S. A. Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - A. Zeevi
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA,Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA,Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - R. T. Fischer
- Department of Pediatric Gastroenterology, University of Nebraska Medical Center, Omaha, NE
| | - B. Feingold
- Division of Pediatric Cardiology, Children's Hospital of Pittsburgh of UPMC and Division of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - H. R. Turnquist
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA,Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA,Corresponding author: Hēth R. Turnquist, PhD,
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13
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Li L, Khush K, Hsieh SC, Ying L, Luikart H, Sigdel T, Roedder S, Yang A, Valantine H, Sarwal MM. Identification of common blood gene signatures for the diagnosis of renal and cardiac acute allograft rejection. PLoS One 2013; 8:e82153. [PMID: 24358149 PMCID: PMC3864873 DOI: 10.1371/journal.pone.0082153] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 10/22/2013] [Indexed: 11/18/2022] Open
Abstract
To test, whether 10 genes, diagnostic of renal allograft rejection in blood, are able to diagnose and predict cardiac allograft rejection, we analyzed 250 blood samples from heart transplant recipients with and without acute rejection (AR) and with cytomegalovirus (CMV) infection by QPCR. A QPCR-based logistic regression model was built on 5 of these 10 genes (AR threshold composite score >37% = AR) and tested for AR prediction in an independent set of 109 samples, where it correctly diagnosed AR with 89% accuracy, with no misclassifications for AR ISHLT grade 1b. CMV infection did not confound the AR score. The genes correctly diagnosed AR in a blood sample within 6 months prior to biopsy diagnosis with 80% sensitivity and untreated grade 1b AR episodes had persistently elevated scores until 6 months after biopsy diagnosis. The gene score was also correlated with presence or absence of cardiac allograft vasculopathy (CAV) irrespective of rejection grade. In conclusion, there is a common transcriptional axis of immunological trafficking in peripheral blood in both renal and cardiac organ transplant rejection, across a diverse recipient age range. A common gene signature, initially identified in the setting of renal transplant rejection, can be utilized serially after cardiac transplantation, to diagnose and predict biopsy confirmed acute heart transplant rejection.
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Affiliation(s)
- Li Li
- Department of Pediatrics, Stanford University, Palo Alto, California, United States of America
| | - Kiran Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, California, United States of America
| | - Szu-Chuan Hsieh
- Department of Pediatrics, Stanford University, Palo Alto, California, United States of America
- California Pacific Medical Center Research Institute, San Francisco, California, United States of America
| | - Lihua Ying
- Department of Pediatrics, Stanford University, Palo Alto, California, United States of America
| | - Helen Luikart
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, California, United States of America
| | - Tara Sigdel
- Department of Pediatrics, Stanford University, Palo Alto, California, United States of America
- California Pacific Medical Center Research Institute, San Francisco, California, United States of America
| | - Silke Roedder
- Department of Pediatrics, Stanford University, Palo Alto, California, United States of America
- California Pacific Medical Center Research Institute, San Francisco, California, United States of America
| | - Andrew Yang
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, California, United States of America
| | - Hannah Valantine
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, California, United States of America
- * E-mail: (MS); (HV)
| | - Minnie M. Sarwal
- Department of Pediatrics, Stanford University, Palo Alto, California, United States of America
- California Pacific Medical Center Research Institute, San Francisco, California, United States of America
- * E-mail: (MS); (HV)
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14
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Flanagan R, Cain N, Tatum G, DeBrunner MG, Drant S, Feingold B. Left ventricular myocardial performance index change for detection of acute cellular rejection in pediatric heart transplantation. Pediatr Transplant 2013; 17:782-6. [PMID: 24118848 PMCID: PMC3841228 DOI: 10.1111/petr.12153] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2013] [Indexed: 01/18/2023]
Abstract
EMB, the gold standard for diagnosis of ACR, poses unique risks in children. Limited cross-sectional data have associated LV MPI with ACR. We hypothesize that a relative change in MPI from baseline without ACR to the time of ACR will better detect ACR than an absolute threshold LV MPI value. We identified 40 children with ACR ≥60 days post-transplant matching them by age and time from transplantation to 40 children without ACR. There was a significant increase in LV MPI at time of ACR vs. baseline (0.59 ± 0.17 vs. 0.41 ± 0.11; p < 0.001). There was no difference in LV MPI between baseline and follow-up (0.41 ± 0.11 vs. 0.42 ± 0.11; p = 0.65). An absolute increase in LV MPI of ≥0.47 had 82.5% sensitivity and 85% specificity for ACR, whereas an increase in LV MPI from baseline of ≥20.4% was 90% sensitive and 100% specific. Serial measurement of LV MPI appears to be a sensitive and specific marker of ACR. LV MPI shows good interobserver agreement and increases at the time of EMB-proven ACR with subsequent resolution to baseline measurements upon EMB-proven resolution of ACR. Future studies in larger, prospective cohorts should be undertaken to validate these findings.
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Affiliation(s)
- Ryan Flanagan
- Children’s Hospital of Pittsburgh of UPMC Division of Pediatric Cardiology, Pittsburgh, PA
| | - Nicole Cain
- Medical University of South Carolina Children’s Hospital Division of Pediatric Cardiology, Charleston SC
| | - Gregory Tatum
- Duke Children’s Hospital and Health Center Division of Pediatric Cardiology, Durham, NC
| | - Mark G. DeBrunner
- Children’s Hospital of Pittsburgh of UPMC Division of Pediatric Cardiology, Pittsburgh, PA
| | - Stacey Drant
- Children’s Hospital of Pittsburgh of UPMC Division of Pediatric Cardiology, Pittsburgh, PA
| | - Brian Feingold
- Children’s Hospital of Pittsburgh of UPMC Division of Pediatric Cardiology, Pittsburgh, PA
,Clinical and Translational Research, University of Pittsburgh, Pittsburgh, PA
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15
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D'Alessandro LC, Mital S. Pediatric transplantation: opportunities for pharmacogenomics and genomics. Per Med 2013; 10:397-404. [PMID: 29783417 DOI: 10.2217/pme.13.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Heterogeneity is the rule among pediatric heart transplant recipients. Patients vary in age, size, organ maturity, immune system maturity and underlying disease etiology, which can all influence post-transplant outcomes. Overall, the survival of pediatric transplant recipients continues to improve and the goal remains long-term survival of the primary graft and mitigation of long-term complications and adverse events. The evolving fields of pharmacogenomics and genomics have the potential to revolutionize and personalize the care of pediatric transplant recipients, and although clinical validation in a pediatric cohort is lacking, many of these technologies are becoming more readily available. We discuss genotype-guided dosing of immunosuppressant medications and other commonly used medications after transplantation, the influence of donor and recipient genotype on risk of post-transplant complications, genotype-guided selection of therapies to treat complications, and the use of next-generation sequencing for noninvasive detection of graft rejection.
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Affiliation(s)
- Lisa Ca D'Alessandro
- Division of Cardiology, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Seema Mital
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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16
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Abstract
OPINION STATEMENT Heart transplantation is the preferred therapy for patients with end-stage heart failure with refractory symptoms despite optimal medical and device therapy. The major impediment to survival is rejection and infection in the short term and cardiac allograft vasculopathy and malignancy in the long term. Current therapies are focused on the prevention and treatment of rejection and limiting the long-term problems of cardiac allograft vasculopathy and malignancy. Advances in monitoring assays now allow better assessment of rejection and the level of immune response. This will allow clinicians, in the future, to tailor current therapies to the needs of individual heart transplant recipients to maximize benefit and minimize toxicity.
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17
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Kransdorf EP, Kobashigawa JA. Genetic and genomic approaches to the detection of heart transplant rejection. Per Med 2012; 9:693-705. [PMID: 29776273 DOI: 10.2217/pme.12.84] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Since Christiaan Barnard performed the first heart transplant in 1967, over 100,000 heart transplants have been performed worldwide. As was true then, rejection remains the major threat to the function and survival of the allograft. The development of the endomyocardial biopsy as a means to monitor for rejection has allowed heart transplantation to thrive as a therapy for patients with end-stage heart disease. The need for a noninvasive method of rejection surveillance led to the development of the first genetic test for allograft rejection, the AlloMap®. In this article, after presenting the pathological and clinical features of cardiac allograft rejection, the authors discuss the development and application of gene-expression testing for the detection of cardiac allograft rejection. We then explore emerging 'omic' approaches that will be the rejection detection methods of the future.
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Affiliation(s)
- Evan P Kransdorf
- Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
| | - Jon A Kobashigawa
- Cedars-Sinai Heart Institute, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA.
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18
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Abstract
Personalized medicine is a broad and rapidly advancing field of health care that is informed by each person's unique clinical, genetic, genomic, and environmental information. Personalized medicine depends on multidisciplinary health care teams and integrated technologies (e.g., clinical decision support) to utilize our molecular understanding of disease in order to optimize preventive health care strategies. Human genome information now allows providers to create optimized care plans at every stage of a disease, shifting the focus from reactive to preventive health care. The further integration of personalized medicine into the clinical workflow requires overcoming several barriers in education, accessibility, regulation, and reimbursement. This review focuses on providing a comprehensive understanding of personalized medicine, from scientific discovery at the laboratory bench to integration of these novel ways of understanding human biology at the bedside.
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Affiliation(s)
- Isaac S Chan
- Center for Genomic Medicine, Institute for Genome Sciences & Policy, Duke University, Durham, North Carolina 27708, USA
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19
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Abstract
It is challenging to monitor the health of transplanted organs, particularly with respect to rejection by the host immune system. Because transplanted organs have genomes that are distinct from the recipient's genome, we used high throughput shotgun sequencing to develop a universal noninvasive approach to monitoring organ health. We analyzed cell-free DNA circulating in the blood of heart transplant recipients and observed significantly increased levels of cell-free DNA from the donor genome at times when an endomyocardial biopsy independently established the presence of acute cellular rejection in these heart transplant recipients. Our results demonstrate that cell-free DNA can be used to detect an organ-specific signature that correlates with rejection, and this measurement can be made on any combination of donor and recipient. This noninvasive test holds promise for replacing the endomyocardial biopsy in heart transplant recipients and may be applicable to other solid organ transplants.
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21
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Aharinejad S, Andrukhova O, Gmeiner M, Thomas A, Aliabadi A, Zuckermann A, Grimm M. Donor myocardial apollon mRNA is associated with cardiac allograft rejection. J Heart Lung Transplant 2010; 29:777-85. [DOI: 10.1016/j.healun.2010.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 03/06/2010] [Accepted: 03/18/2010] [Indexed: 11/30/2022] Open
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22
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Mendrick DL, Schnackenberg L. Genomic and metabolomic advances in the identification of disease and adverse event biomarkers. Biomark Med 2010; 3:605-15. [PMID: 20477528 DOI: 10.2217/bmm.09.43] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Incomplete knowledge of tissue pathogenesis is hampering the identification of biomarkers for the appropriate therapeutic targets to prevent or inhibit disease processes, and the prediction and diagnosis of injury due to disease and adverse events of drug therapy. The revolution in genomics and metabolomics, combined with advanced bioinformatics and computational methods for mining such large, complex data sets, are beginning to provide critical insights into tissue injury. Such results will move us closer to the promise of personalized medicine.
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Affiliation(s)
- Donna L Mendrick
- Division of Systems Toxicology, HFT-230, National Center for Toxicological Research, US FDA, 3900 NCTR Road, Jefferson, AR 72079-4502, USA.
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23
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Quo Vadis? The Society for Cardiovascular Pathology over the next 25 years and beyond. Cardiovasc Pathol 2010; 19:195-7. [PMID: 20418116 DOI: 10.1016/j.carpath.2010.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 03/25/2010] [Indexed: 11/22/2022] Open
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24
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Abstract
Clinicians have long awaited an alternative to invasive endomyocardial biopsy for surveillance of cardiac transplant rejection. Transcriptional signals in peripheral blood mononuclear cells allow for the development of multigene-based panels that can inform on the presence or absence of immunologic quiescence. The informative genes represent several biologic pathways, including T-cell activation (PDCD1), T-cell migration (ITGA4), and mobilization of hematopoietic precursors (WDR40A and microRNA gene family cMIR), and steroid-responsive genes such as IL1R2, the decoy receptor for interleukin 2. The greatest value may include the ability to inform on the potential of future proclivity for rejection, allowing patients to be stratified into low, intermediate, or high risk subsets for future rejection. In these individuals, this knowledge may allow clinicians to use tailored approaches to immunosuppression, thereby avoiding adverse pharmacologic effects in low-risk patients while improving rejection outcomes in those at high risk for future allograft compromise. Despite these advances, clinical entrenchment of gene-based pharmacotherapy in cardiac transplantation will require independent replication and validation of investigational findings.
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Affiliation(s)
- Mandeep R Mehra
- Division of Cardiology, University of Maryland School of Medicine, 22 South Greene Street-S3B06, Baltimore, MD 21201, USA.
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25
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Whole blood genomic biomarkers of acute cardiac allograft rejection. J Heart Lung Transplant 2010; 28:927-35. [PMID: 19716046 DOI: 10.1016/j.healun.2009.04.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 03/17/2009] [Accepted: 04/10/2009] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Significant progress has been made in cardiac transplantation over the past 30 years; however, the means for detection of acute cardiac allograft rejection remains in need of improvement. At present, the endomyocardial biopsy, an invasive and inconvenient procedure for patients, is required for the surveillance and diagnosis of acute cardiac allograft rejection. In the Biomarkers in Transplantation initiative, we investigated gene expression profiles in peripheral blood of cardiac transplant subjects as potential biomarkers for diagnosis of allograft rejection. METHODS Whole blood samples were obtained from 28 cardiac transplant subjects who consented to the study. Serial samples were collected from pre-transplant through 3 years post-transplant according to the standard protocol. Temporally correspondent biopsies were also collected, reviewed in a blinded manner, and graded according to current ISHLT guidelines. Blood samples were analyzed using Affymetrix microarrays. Genomic profiles were compared in subjects with acute rejection (AR; ISHLT Grade > or =2R) and no rejection (NR; Grade 0R). Biomarker panel genes were identified using linear discriminant analysis. RESULTS We found 1,295 differentially expressed probe-sets between AR and NR samples and developed a 12-gene biomarker panel that classifies our internal validation samples with 83% sensitivity and 100% specificity. CONCLUSIONS Based on our current results, we believe whole blood genomic biomarkers hold great potential in the diagnosis of acute cardiac allograft rejection. A prospective, Canada-wide trial will be conducted shortly to further evaluate the classifier panel in diverse patients and a range of clinical programs.
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26
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Ginsburg GS, Willard HF. Genomic and personalized medicine: foundations and applications. Transl Res 2009; 154:277-87. [PMID: 19931193 DOI: 10.1016/j.trsl.2009.09.005] [Citation(s) in RCA: 283] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Accepted: 09/16/2009] [Indexed: 11/15/2022]
Abstract
The last decade has witnessed a steady embrace of genomic and personalized medicine by senior government officials, industry leadership, health care providers, and the public. Genomic medicine, which is the use of information from genomes and their derivatives (RNA, proteins, and metabolites) to guide medical decision making-is a key component of personalized medicine, which is a rapidly advancing field of health care that is informed by each person's unique clinical, genetic, genomic, and environmental information. As medicine begins to embrace genomic tools that enable more precise prediction and treatment disease, which include "whole genome" interrogation of sequence variation, transcription, proteins, and metabolites, the fundamentals of genomic and personalized medicine will require the development, standardization, and integration of several important tools into health systems and clinical workflows. These tools include health risk assessment, family health history, and clinical decision support for complex risk and predictive information. Together with genomic information, these tools will enable a paradigm shift to a comprehensive approach that will identify individual risks and guide clinical management and decision making, all of which form the basis for a more informed and effective approach to patient care. DNA-based risk assessment for common complex disease, molecular signatures for cancer diagnosis and prognosis, and genome-guided therapy and dose selection are just among the few important examples for which genome information has already enabled personalized health care along the continuum from health to disease. In addition, information from individual genomes, which is a fast-moving area of technological development, is spawning a social and information revolution among consumers that will undoubtedly affect health care decision making. Although these and other scientific findings are making their way from the genome to the clinic, the full application of genomic and personalized medicine in health care will require dramatic changes in regulatory and reimbursement policies as well as legislative protections for privacy for system-wide adoption. Thus, there are challenges from both a scientific and a policy perspective to personalized health care; however, they will be confronted and solved with the certainty that the science behind genomic medicine is sound and the practice of medicine that it informs is evidence based.
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Affiliation(s)
- Geoffrey S Ginsburg
- Duke Institute for Genome Sciences & Policy, Duke University, Durham, NC 27708, USA.
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27
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Crespo-Leiro M, Paniagua-Martín M, Hermida-Prieto M, Castro-Beiras A. Gene Expression Profiling for Monitoring Graft Rejection in Heart Transplant Recipients. Transplant Proc 2009; 41:2240-3. [DOI: 10.1016/j.transproceed.2009.06.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Aharinejad S, Krenn K, Zuckermann A, Schäfer R, Gmeiner M, Thomas A, Aliabadi A, Schneider B, Grimm M. Serum matrix metalloprotease-1 and vascular endothelial growth factor--a predict cardiac allograft rejection. Am J Transplant 2009; 9:149-59. [PMID: 19067665 DOI: 10.1111/j.1600-6143.2008.02470.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cardiac allograft rejection is currently diagnosed from endomyocardial biopsies (EMB) that are invasive and impractical to repeat. A serological marker could facilitate rejection monitoring and minimize EMB-associated risks. We investigated the relation of serum matrix metalloprotease (MMP)-1 and vascular endothelial growth factor (VEGF)-A concentrations to cardiac allograft rejection, using 1176 EMBs and serum samples obtained from 208 recipients. Acute cellular rejection was diagnosed in 186 EMBs. Mean week 1 and week 2 serum MMP-1 concentrations predicted rejection (p = 0.001, AUC = 0.80). At the optimal cut-off level of >or=7.5 ng/mL, MMP-1 predicted rejection with 82% sensitivity and 72% specificity. Initial serum MMP-1 <5.3 ng/mL (lowest quartile) was associated with rejection-free outcome in 80% of patients. Both MMP-1 (p < 0.001, AUC = 0.67-0.75) and VEGF-A (p < 0.01, AUC = 0.62-0.67) predicted rejection on the next EMB, while rejection at EMB was identified only by VEGF-A (p < 0.02, AUC = 0.70-0.77). Patients receiving combined cyclosporine-A and everolimus had the lowest serum MMP-1 concentrations. While serum MMP-1 predicts rejection-free outcome and VEGF-A identifies rejection on EMB, both markers predict rejection in follow-up of cardiac transplant recipients. Combination of serum MMP-1 and VEGF-A concentration may be a noninvasive prognostic marker of cardiac allograft rejection, and could have important implications for choice of surveillance and immunosuppression protocols.
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Affiliation(s)
- S Aharinejad
- Department of Cardiothoracic Surgery, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
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29
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Mendrick DL. Genomic and genetic biomarkers of toxicity. Toxicology 2008; 245:175-81. [DOI: 10.1016/j.tox.2007.11.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 11/20/2007] [Indexed: 11/28/2022]
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Aziz H, Zaas A, Ginsburg GS. Peripheral blood gene expression profiling for cardiovascular disease assessment. Genomic Med 2008; 1:105-12. [PMID: 18923935 DOI: 10.1007/s11568-008-9017-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2008] [Accepted: 01/25/2008] [Indexed: 12/18/2022] Open
Abstract
Whole blood gene expression profiling has the potential to be informative about dynamic changes in disease states and to provide information on underlying disease mechanisms. Having demonstrated proof of concept in animal models, a number of studies have now tried to tackle the complexity of cardiovascular disease in human hosts to develop better diagnostic and prognostic indicators. These studies show that genomic signatures are capable of classifying patients with cardiovascular diseases into finer categories based on the molecular architecture of a patient's disease and more accurately predict the likelihood of a cardiovascular event than current techniques. To highlight the spectrum of potential applications of whole blood gene expression profiling approach in cardiovascular science, we have chosen to review the findings in a number of complex cardiovascular diseases such as atherosclerosis, hypertension and myocardial infarction as well as thromboembolism, aortic aneurysm, and heart transplant.
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Affiliation(s)
- Hamza Aziz
- School of Medicine, Duke University, Durham, USA
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31
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Abstract
There is a need for new biomarkers to enable faster detection of adverse events due to drugs and disease processes. One would prefer biomarkers that are useful in multiple species (i.e., translational or bridging biomarkers) so that it would be possible to directly link responses between species and follow such injury in both preclinical and clinical settings. This chapter will explore some of the issues surrounding the use of pharmacogenomics to identify and qualify such biomarkers, and examples will be provided.
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Affiliation(s)
- Donna L Mendrick
- Department of Toxicogenomics, Gene Logic Inc., Gaithersburg, Maryland, USA
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32
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Dev S, Lloyd-Jones DM. Problems associated with screening for asymptomatic cardiac transplant rejection. J Heart Lung Transplant 2007; 26:1219; author reply 1219-20. [PMID: 18022094 DOI: 10.1016/j.healun.2007.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 04/10/2007] [Accepted: 04/13/2007] [Indexed: 11/26/2022] Open
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33
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Starling RC, Deng M, Mehra M. Authors’ Reply. J Heart Lung Transplant 2007. [DOI: 10.1016/j.healun.2007.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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34
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Mohr S, Liew CC. The peripheral-blood transcriptome: new insights into disease and risk assessment. Trends Mol Med 2007; 13:422-32. [PMID: 17919976 DOI: 10.1016/j.molmed.2007.08.003] [Citation(s) in RCA: 219] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2007] [Revised: 08/12/2007] [Accepted: 08/12/2007] [Indexed: 12/14/2022]
Abstract
Future personalized medicine strategies for assessing an individual's health require, ideally, a noninvasive system that is capable of integrating numerous interactive factors, including gender, age, genetics, behavior, environment and comorbidities. Several microarray-based methods developed to meet this goal are currently under investigation. However, most rely on tissue biopsies, which are not readily available or accessible. As an alternative, several recent studies have investigated the use of human peripheral blood cells as surrogate biopsy material. Such studies are based on the assumption that molecular profiling of circulating blood might reflect physiological and pathological events occurring in different tissues of the body. This has led to the development of novel methods for identifying and monitoring blood biomarkers to probe an individual's health status. Here, we discuss the rationale and clinical potential of profiling the peripheral-blood transcriptome.
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Affiliation(s)
- Steve Mohr
- GeneNews Corp., 2-2 East Beaver Creek Road, Richmond Hill, Ontario, L4B 2N3, Canada.
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35
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36
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Pham MX, Deng MC, Kfoury AG, Teuteberg JJ, Starling RC, Valantine H. Molecular Testing for Long-term Rejection Surveillance in Heart Transplant Recipients: Design of the Invasive Monitoring Attenuation Through Gene Expression (IMAGE) Trial. J Heart Lung Transplant 2007; 26:808-14. [PMID: 17692784 DOI: 10.1016/j.healun.2007.05.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 05/09/2007] [Accepted: 05/28/2007] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Acute rejection continues to occur beyond the first year after cardiac transplantation, but the optimal strategy for detecting rejection during this late period is still controversial. Gene expression profiling (GEP), with its high negative predictive value for acute cellular rejection (ACR), appears to be well suited to identify low-risk patients who can be safely managed without routine invasive endomyocardial biopsy (EMB). METHODS The Invasive Monitoring Attenuation Through Gene Expression (IMAGE) study is a prospective, multicenter, non-blinded, randomized clinical trial designed to test the hypothesis that a primarily non-invasive rejection surveillance strategy utilizing GEP testing is not inferior to an invasive EMB-based strategy with respect to cardiac allograft dysfunction, rejection with hemodynamic compromise (HDC) and all-cause mortality. RESULTS A total of 199 heart transplant recipients in their second through fifth post-transplant years have been enrolled in the IMAGE study since January 13, 2005. The study is expected to continue through 2008. CONCLUSIONS The IMAGE study is the first randomized, controlled comparison of two rejection surveillance strategies measuring outcomes in heart transplant recipients who are beyond their first year post-transplant. The move away from routine histologic evaluation for allograft rejection represents an important paradigm shift in cardiac transplantation, and the results of this study have important implications for the future management of heart transplant patients.
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Affiliation(s)
- Michael X Pham
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA
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37
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Mendrick DL, Daniels KK. From the bench to the clinic and back again: translational biomarker discovery using in silico mining of pharmacogenomic data. Biomark Med 2007; 1:319-33. [PMID: 20477406 DOI: 10.2217/17520363.1.2.319] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
To improve drug efficacy and safety and advance medical intervention in diseases, new biomarkers are urgently needed. Pharmacogenomics can provide a tool to discover and begin to qualify biomarkers useful for these indications and is readily applicable to multiple species. One can begin and end with genes or focus on tissue-derived expression analysis of those genes that encode secreted proteins to discover potential biomarkers that can be monitored in body fluids. The paper will discuss issues surrounding such investigations, show examples of translational biomarkers and end with a summary of the US FDA’s work in this field over the last 6 years.
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Affiliation(s)
- Donna L Mendrick
- Gene Logic Inc., 50 West Watkins Mill Road, Gaithersburg, MA 20878, USA
| | - Kellye K Daniels
- Gene Logic Inc., 50 West Watkins Mill Road, Gaithersburg, MA 20878, USA
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Heidecker B, Hare JM. The use of transcriptomic biomarkers for personalized medicine. Heart Fail Rev 2007; 12:1-11. [PMID: 17393305 DOI: 10.1007/s10741-007-9004-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Accepted: 02/13/2007] [Indexed: 12/29/2022]
Abstract
Microarrays are a high throughput technology that allows the quantification of tens of thousands of RNA transcripts in a single reaction. This new technology offers the promise of comprehensive study of disease at a genomic level, potentially identifying novel molecular abnormalities, developing novel clinical biomarkers, and investigating drug efficacy. The ability to develop a molecular profile corresponding to a therapeutic effect is the basis for the concept of drug repositioning. With regard to prediction of clinical events, microarray technology has the potential to contribute to the development of sophisticated new biomarkers useful as predictors of disease etiology, outcome, and responsiveness to therapy-so-called personalized medicine. Currently progress in the field is hampered by a degree of skepticism about the reliability of microarray data and its relevance for clinical applications. Here we discuss possible pitfalls of transcriptomic analysis, review current developments in the cardiovascular area and address the use of transcriptomics for clinical applications.
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Affiliation(s)
- Bettina Heidecker
- Divison of Cardiology, Miller School of Medicine, University of Miami, Clinical Research Building, 1120 NW 14th Street, Suite 1112, Miami, FL 33136, USA
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Rivard AL, Swingen CM, Blake D, Huang AS, Kanth P, Thomsen GF, Cordova EJ, Miller LW, Bianco RW, Wilke N. A comparison of myocardial perfusion and rejection in cardiac transplant patients. Int J Cardiovasc Imaging 2007; 23:575-82. [PMID: 17206459 DOI: 10.1007/s10554-006-9184-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2006] [Accepted: 10/17/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Although histological evaluation of the cardiac tissue is the current gold standard for evaluation of rejection, we hypothesized that cardiac perfusion MRI is a safe non-invasive method that correlates tissue blood flow changes with biopsy proven rejection in the cardiac transplant patient. MATERIALS AND METHODS In a retrospective study from 1984-2001, 83 patients underwent 135 MR Gd-DTPA imaging studies. In 8 patients (9%), biopsies graded 2 or higher (by ISHLT criteria) provided evidence of rejection. Patients were age and sex matched to 11 non-rejected controls for imaging analysis. Time-signal intensity curves generated for a mid-ventricle LV short axis slice during rest and adenosine stress allowed determination of myocardial blood flow (MBF, ml/min/gm). ROC curve analysis by SPSS allowed estimation of sensitivity and specificity. RESULTS At rest, there was no difference in MBF between patients with prior rejection vs. those without (1.18 +/- 0.26 vs. 1.16 +/- 0.29). At stress there was a decrease in MBF for patients with prior rejection episodes (3.27 +/- 0.74) compared to no rejection (3.60 +/- 0.72), P = 0.067). The area under the ROC curve was 0.82, with specificity and sensitivity of 75% and 81%, respectively. CONCLUSION This study suggests that perfusion MR imaging can be used in assessing the cardiac transplant patient for rejection related microvascular changes. The high specificity and sensitivity recorded from the ROC curve illustrates the potential utility of this diagnostic test for future studies.
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Affiliation(s)
- Andrew L Rivard
- Department of Surgery, Experimental Surgical Services, University of Minnesota, MMC 220, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
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Abstract
Many achievements in the genome sciences have been facilitated by policies that have prioritized genome research, secured funding and raised public and health-professional awareness. Such policies should address ethical, legal and social concerns, and are as important to the scientific and commercial development of the field as the science itself. On occasion, policy issues take precedence over science, particularly when impasses are encountered or when public health or money is at stake. Here we discuss the spectrum of current issues and debates in genome policy, and how to actively engage all affected stakeholders to promote effective policy making.
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Affiliation(s)
- Susanne B Haga
- Institute for Genome Sciences & Policy, Duke University, 101 Science Drive, Box 3382, Durham, North Carolina 27708, USA.
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41
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Abstract
The landmark sequencing of the human genome has ushered in a new field of large-scale research. Advances in understanding the molecular basis of disease have opened up new opportunities to develop genomics-based tools to diagnose, predict disease onset or recurrence, tailor treatment options, and assess treatment response. Although still in the early stages of research and development, genomic biomarker research has the capability of providing a comprehensive insight into pathophysiological processes as well as more precise predictors of outcome not previously attainable with traditional biomarkers. Before genomic biomarkers are incorporated into clinical practice, several issues will need to be addressed in order to generate the necessary levels of evidence to demonstrate analytical and clinical validity and utility. In addition, efforts will be needed to educate health professionals and the public about genomics-based tools, revise regulatory oversight mechanisms, and ensure privacy safeguards of the information generated from these new tests.
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Affiliation(s)
- Geoffrey S Ginsburg
- Center for Genomic Medicine, Institute for Genome Sciences & Policy, Duke University, Box 3382, Durham, NC 27708, USA.
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Burczynski ME, Dorner AJ. Transcriptional profiling of peripheral blood cells in clinical pharmacogenomic studies. Pharmacogenomics 2006; 7:187-202. [PMID: 16515398 DOI: 10.2217/14622416.7.2.187] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Peripheral blood represents an attractive tissue source in clinical pharmacogenomic studies, given the feasibility of its collection from patients and its potential as a sentinel tissue to monitor perturbations of physiology in many disease states. The hypothesis is that the circulating blood cells monitor the physiological state of the organism and alter their transcriptome in response to this surveillance. However, the successful implementation of transcriptional profiling of peripheral blood cells in clinical trials represents a tremendous technical challenge for several reasons, including controlling the pre-analytical variables associated with sample processing and the interpretation of gene expression signatures generated from the complex mixture of cell types in blood. Multiple approaches for identifying transcriptomes in peripheral blood cells exist and each method is associated with significant advantages and disadvantages. Nonetheless, a growing number of studies are rapidly identifying transcriptional biomarkers in peripheral blood cells that may function as biomarkers of disease, evidence of pharmacodynamic effect, or even predictors of clinical outcomes and risk of toxicity. This review highlights the major approaches employed in global transcriptional profiling of peripheral blood cells and summarizes the available literature of initial studies in the growing field of hemogenomics. The overall purpose of the review is to focus on the development and application of technologies for the use of peripheral blood cells as a sentinel or surrogate tissue to measure disease state and drug response.
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Affiliation(s)
- Michael E Burczynski
- Wyeth Research, Pharmacogenomic Biomarkers, Biomarker Laboratory, 500 Arcola Road, Collegeville, PA 19426, USA.
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Machnicki G, Seriai L, Schnitzler MA. Economics of transplantation: a review of the literature. Transplant Rev (Orlando) 2006. [DOI: 10.1016/j.trre.2006.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Mehra MR, Feller E, Rosenberg S. The promise of protein-based and gene-based clinical markers in heart transplantation: from bench to bedside. ACTA ACUST UNITED AC 2006; 3:136-43. [PMID: 16505859 DOI: 10.1038/ncpcardio0457] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Accepted: 11/08/2005] [Indexed: 01/17/2023]
Abstract
Advances in immunosuppression, guided by invasive endomyocardial biopsy for the assessment of graft rejection, have ushered heart transplantation into the clinical arena by the demonstration of acceptable 1-year outcomes. Further decreases in the risk of malignancy and cardiac allograft vasculopathy that improve long-term outcomes, are, however, still desired. Attention has become directed towards the use of markers that can be detected noninvasively to provide insight into underlying molecular and cellular events associated with the immune response and graft function. Various candidate, protein-based markers have been identified: those of alloimmune activation; those of microvascular injury, such as cardiac-specific troponins; those of inflammation, including C-reactive protein; and surrogate markers of cardiac function, including natriuretic peptides such as brain natriuretic peptide. In the realm of genomics, it is becoming increasingly clear that a single molecular marker is unlikely to prove to be useful, but rather that multiple genes from a number of pathways are needed to capture biological complexity and overcome variability in the general population. Thus, the field of protein-based and gene-based biomarkers is advancing rapidly to define its place in clinical therapeutics and to guide immunosuppression according to molecular mechanisms of disease. We discuss here the main findings for the more-successful protein markers identified so far, and the genomic molecular approaches being used to improve heart transplant outcomes.
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Affiliation(s)
- Mandeep R Mehra
- Division of Cardiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Jiménez Navarro MF, Díez Martínez J, Delgado Jiménez JF, Crespo Leiro MG. La insuficiencia cardíaca en el año 2005. Rev Esp Cardiol 2006; 59 Suppl 1:55-65. [PMID: 16540021 DOI: 10.1157/13084449] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article is a review of developments reported in the field of heart failure in the last year. It covers advances in epidemiology, pathophysiology and therapy, including cardiac resynchronization therapy and heart transplantation. Today, management of heart failure is complex. It depends on the participation of numerous health professionals under the guidance of a cardiologist. The increasing prevalence of heart failure means that continuing research is mandatory.
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46
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Raulf F. Novel biomarkers of allograft rejection: ???omics??? approaches start to deliver. Curr Opin Organ Transplant 2005. [DOI: 10.1097/01.mot.0000184016.85831.dc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Podgoreanu MV, Schwinn DA. New Paradigms in Cardiovascular Medicine. J Am Coll Cardiol 2005; 46:1965-77. [PMID: 16325027 DOI: 10.1016/j.jacc.2005.08.040] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Revised: 08/05/2005] [Accepted: 08/17/2005] [Indexed: 12/26/2022]
Abstract
Considerable progress has been made in understanding the pathophysiology of perioperative stress responses and their impact on the cardiovascular system; however, researchers are just beginning to unravel genetic and molecular determinants that predispose to increased risk for postoperative cardiovascular adverse events. A new field, coined perioperative genomics, aims to apply functional genomic approaches to uncover the biological reasons why similar patients can have dramatically different clinical outcomes after surgery. For the perioperative physician, such findings may soon translate into prospective risk assessment incorporating genomic profiling of markers important in inflammatory, thrombotic, vascular, and neurologic responses to perioperative stress, with implications ranging from individualized additional pre-operative testing and physiological optimization, to perioperative decision-making, choice of monitoring strategies, and critical care resource utilization. We review current knowledge regarding genomic technologies in perioperative cardiovascular disease characterization and outcome prediction, as well as discuss future trends/challenges for translating integrated "omic" information into daily clinical management of the surgical patient.
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Affiliation(s)
- Mihai V Podgoreanu
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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