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Khush K, Hall S, Kao A, Raval N, Dhingra R, Shah P, Bellumkonda L, Ravichandran A, Van Bakel A, Uriel N, Patel S, Pinney S, DePasquale E, Baran D, Pinney K, Oreschak K, Kobulnik J, Shen L, Teuteberg J. Surveillance with Dual Non-invasive Testing for Acute Cellular Rejection After Heart Transplantation: Outcomes from the Surveillance HeartCare Outcomes Registry (SHORE). J Heart Lung Transplant 2024:S1053-2498(24)01659-0. [PMID: 38759766 DOI: 10.1016/j.healun.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Molecular testing with gene expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA) is increasingly used in the surveillance for acute cellular rejection (ACR) after heart transplant. However, the performance of dual testing over each test individually has not been established. Further, the impact of dual non-invasive surveillance on clinical decision-making has not been widely investigated. METHODS We evaluated 2077 subjects from the SHORE registry who were enrolled between 2018 and 2021 and had verified biopsy data, and were categorized as dual negative, GEP positive/dd-cfDNA negative, GEP negative/dd-cfDNA positive, or dual positive. Incidence of ACR and follow-up testing rates for each group were evaluated. Positive likelihood ratios (LR+) were calculated and biopsy rates over time were analyzed. RESULTS The incidence of ACR was 1.5% for dual negative, 1.9% for GEP positive/dd-cfDNA negative, 4.3% for GEP negative/dd-cfDNA positive and 9.2% for dual positive groups. Follow-up biopsies were performed after 8.8% for dual negative, 14.2% for GEP positive/dd-cfDNA negative, 22.8% for GEP negative/dd-cfDNA positive and 35.4% for dual positive results. The LR+ for ACR was 1.37, 2.91 and 3.90 for GEP positive, dd-cfDNA positive and dual positive testing, respectively. From 2018-2021, first-year biopsy rates declined from 5.9 to 5.3 biopsies/patient, and second year from 1.5 to 0.9 biopsies/patient. At two-years, survival was 94.9% and only 2.7% had graft dysfunction. CONCLUSIONS Dual molecular testing demonstrated improved performance for ACR surveillance compared to single molecular testing. Use of dual non-invasive testing was associated with lower biopsy rates over time, excellent survival, and low incidence of graft dysfunction.
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Affiliation(s)
| | | | - Andrew Kao
- St. Luke's Health System Kansas City Mid America Heart Institute
| | - Nirav Raval
- AdventHealth Transplant Institute, Orlando, FL
| | | | - Palak Shah
- Inova Heart and Vascular Institute, Fairfax, VA
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Halloran PF, Reeve J, Mackova M, Madill-Thomsen KS, Demko Z, Olymbios M, Campbell P, Melenovsky V, Gong T, Hall S, Stehlik J. Comparing Plasma Donor-derived Cell-free DNA to Gene Expression in Endomyocardial Biopsies in the Trifecta-Heart Study. Transplantation 2024:00007890-990000000-00702. [PMID: 38538559 DOI: 10.1097/tp.0000000000004986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
BACKGROUND Plasma donor-derived cell-free DNA (dd-cfDNA) is used to screen for rejection in heart transplants. We launched the Trifecta-Heart study (ClinicalTrials.gov No. NCT04707872), an investigator-initiated, prospective trial, to examine the correlations between genome-wide molecular changes in endomyocardial biopsies (EMBs) and plasma dd-cfDNA. The present report analyzes the correlation of plasma dd-cfDNA with gene expression in EMBs from 4 vanguard centers and compared these correlations with those in 604 kidney transplant biopsies in the Trifecta-Kidney study (ClinicalTrials.gov No. NCT04239703). METHODS We analyzed 137 consecutive dd-cfDNA-EMB pairs from 70 patients. Plasma %dd-cfDNA was measured by the Prospera test (Natera Inc), and gene expression in EMBs was assessed by Molecular Microscope Diagnostic System using machine-learning algorithms to interpret rejection and injury states. RESULTS Top transcripts correlating with dd-cfDNA were related to genes increased in rejection such as interferon gamma-inducible genes (eg, HLA-DMA ) but also with genes induced by injury and expressed in macrophages (eg, SERPINA1 and HMOX1 ). In gene enrichment analysis, the top dd-cfDNA-correlated genes reflected inflammation and rejection pathways. Dd-cfDNA correlations with rejection genes in EMB were similar to those seen in kidney transplant biopsies, with somewhat stronger correlations for TCMR genes in hearts and ABMR genes in kidneys. However, the correlations with parenchymal injury-induced genes and macrophage genes were much stronger in hearts. CONCLUSIONS In this first analysis of Trifecta-Heart study, dd-cfDNA correlates significantly with molecular rejection but also with injury and macrophage infiltration, reflecting the proinflammatory properties of injured cardiomyocytes. The relationship supports the utility of dd-cfDNA in clinical management of heart transplant recipients.
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Affiliation(s)
- Philip F Halloran
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
| | - Jeff Reeve
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
| | - Martina Mackova
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
| | - Katelynn S Madill-Thomsen
- Alberta Transplant Applied Genomics Center, Edmonton, AB, Canada
- Transcriptome Sciences Inc, Edmonton, AB, Canada
| | | | | | | | | | | | | | - Josef Stehlik
- Department of Internal Medicine, University of Utah, Salt Lake City, UT
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3
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Holzhauser L, DeFilippis EM, Nikolova A, Byku M, Contreras JP, De Marco T, Hall S, Khush KK, Vest AR. The End of Endomyocardial Biopsy?: A Practical Guide for Noninvasive Heart Transplant Rejection Surveillance. JACC Heart Fail 2023; 11:263-276. [PMID: 36682960 DOI: 10.1016/j.jchf.2022.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 01/13/2023]
Abstract
Noninvasive heart transplant rejection surveillance using gene expression profiling (GEP) to monitor immune activation is widely used among heart transplant programs. With the new development of donor-derived cell-free DNA (dd-cfDNA) assays, more programs are transitioning to a predominantly noninvasive rejection surveillance protocol with a reduced frequency of endomyocardial biopsies. As a result, many practical questions arise that potentially delay implementation of these valuable new tools. The purpose of this review is to provide practical guidance for clinicians transitioning toward a less invasive acute rejection monitoring protocol after heart transplantation, and to answer 10 common questions about the GEP and dd-cfDNA assays. Evidence supporting GEP and dd-cfDNA testing is reviewed, as well as guidance on test interpretation and future directions.
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Affiliation(s)
- Luise Holzhauser
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Andriana Nikolova
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mirnela Byku
- Department of Cardiology, University of North Carolina in Chapel Hill, North Carolina, USA
| | | | - Teresa De Marco
- Division of Cardiology, University of California, San Francisco, California, USA
| | - Shelley Hall
- Baylor University Medical Center, Dallas, Texas, USA
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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4
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Henricksen EJ, Moayedi Y, Purewal S, Twiggs JV, Waddell K, Luikart H, Han J, Feng K, Wayda B, Lee R, Shudo Y, Jimenez S, Khush KK, Teuteberg JJ. Combining donor derived cell free DNA and gene expression profiling for non-invasive surveillance after heart transplantation. Clin Transplant 2023; 37:e14699. [PMID: 35559582 DOI: 10.1111/ctr.14699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/11/2022] [Accepted: 04/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Donor-derived cell free DNA (dd-cfDNA) and gene expression profiling (GEP) offer noninvasive alternatives to rejection surveillance after heart transplantation; however, there is little evidence on the paired use of GEP and dd-cfDNA for rejection surveillance. METHODS A single center, retrospective analysis of adult heart transplant recipients. A GEP cohort, transplanted from January 1, 2015 through December 31, 2017 and eligible for rejection surveillance with GEP was compared to a paired testing cohort, transplanted July 1, 2018 through June 30, 2020, with surveillance from both dd-cfDNA and GEP. The primary outcomes were survival and rejection-free survival at 1 year post-transplant. RESULTS In total 159 patients were included, 95 in the GEP and 64 in the paired testing group. There were no differences in baseline characteristics, except for less use of induction in the paired testing group (65.6%) compared to the GEP group (98.9%), P < .01. At 1-year, there were no differences between the paired testing and GEP groups in survival (98.4% vs. 94.7%, P = .23) or rejection-free survival (81.3% vs. 73.7% P = .28). CONCLUSIONS Compared to post-transplant rejection surveillance with GEP alone, pairing dd-cfDNA and GEP testing was associated with similar survival and rejection-free survival at 1 year while requiring significantly fewer biopsies.
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Affiliation(s)
| | - Yasbanoo Moayedi
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Saira Purewal
- University of Arizona College of Medicine, Tucson, Arizona, USA
| | | | - Kian Waddell
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Helen Luikart
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Jiho Han
- Internal Medicine, Stanford University, Stanford, California, USA
| | - Kent Feng
- Internal Medicine, Stanford University, Stanford, California, USA
| | - Brian Wayda
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Roy Lee
- Transplant, Stanford Health Care, Stanford, California, USA
| | - Yasuhiro Shudo
- Cardiovascular Surgery, Stanford University, Stanford, California, USA
| | - Shirin Jimenez
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Kiran K Khush
- Cardiovascular Medicine, Stanford University, Stanford, California, USA
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5
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Bart NK, Emmanuel S, Friits-Lamora R, Larkins E, Kotlyar E, Muthiah K, Jabbour A, Hayward C, Jansz PC, Keogh AM, Thomas E, Macdonald PS. Rapid triage and transition to telehealth for heart transplant patients in the COVID-19 pandemic setting. J Telemed Telecare 2023:1357633X231151714. [PMID: 36793232 PMCID: PMC9936174 DOI: 10.1177/1357633x231151714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/30/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND In the setting of the COVID-19 pandemic, a rapid uptake of telehealth services was instituted with the aim of reducing the spread of disease to vulnerable patient populations including heart transplant recipients. METHODS Single-center, cohort study of all heart transplant patients seen by our institution's transplant program during the first 6 weeks of transition from in-person consultation to telehealth (23 March - 5 June 2020). RESULTS Face-to-face consultation allocation strongly favored patients in the early post-operative period (34 vs. 242 weeks post-transplant; p < 0.001). Telehealth consultation dramatically reduced patient travel and wait times (80 min per visit saved in telehealth patients). No apparent excess re-hospitalization or mortality was seen in telehealth patients. CONCLUSIONS With appropriate triage, telehealth was feasible in heart transplant recipients, with videoconferencing being the preferred modality. Patients seen face-to-face were those triaged to be higher acuity based on time since transplant and overall clinical status. These patients have the expected higher rates of hospital re-admission, and therefore should continue to be seen in person.
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Affiliation(s)
- Nicole K Bart
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Medicine, University of Notre Dame, Notre Dame, USA
- School of Medicine, University of New South Wales, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Sam Emmanuel
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Medicine, University of Notre Dame, Notre Dame, USA
- School of Medicine, University of New South Wales, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Rodrigo Friits-Lamora
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Emily Larkins
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Eugene Kotlyar
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Medicine, University of Notre Dame, Notre Dame, USA
- School of Medicine, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Kavitha Muthiah
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Medicine, University of New South Wales, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Andrew Jabbour
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Medicine, University of New South Wales, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Christopher Hayward
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Medicine, University of New South Wales, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Paul C Jansz
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Medicine, University of New South Wales, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Anne M Keogh
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Medicine, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Emma Thomas
- Centre for Health Sciences Research, Faculty of Medicine, University of Queensland, Saint Lucia, Queensland, Australia
| | - Peter S Macdonald
- Heart Transplant Program, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Medicine, University of New South Wales, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
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Kim PJ, Olymbios M, Siu A, Wever Pinzon O, Adler E, Liang N, Swenerton R, Sternberg J, Kaur N, Ahmed E, Chen YA, Fehringer G, Demko ZP, Billings PR, Stehlik J. A novel donor-derived cell-free DNA assay for the detection of acute rejection in heart transplantation. J Heart Lung Transplant 2022; 41:919-927. [PMID: 35577713 PMCID: PMC9670834 DOI: 10.1016/j.healun.2022.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 03/06/2022] [Accepted: 04/04/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Endomyocardial biopsy (EMB), the reference surveillance test for acute rejection (AR) in heart transplant (HTx) recipients, is invasive, costly, and shows significant interobserver variability. Recent studies indicate that donor-derived cell-free DNA (dd-cfDNA), obtained non-invasively from blood, is associated with AR and could reduce the frequency of EMB surveillance. The aim of this study was to examine the performance characteristics of a novel test for detecting AR in adult HTx recipients. METHODS Plasma samples with contemporaneous EMBs were obtained from HTx recipients. A clinically available SNP-based massively multiplexed-PCR dd-cfDNA assay was used to measure dd-cfDNA fraction. dd-cfDNA fractions were compared with EMB-defined rejection status and test performance was assessed by constructing ROC curves and calculating accuracy measures. RESULTS A total of 811 samples from 223 patients with dd-cfDNA testing and contemporaneous EMB were eligible for the study. dd-cfDNA fraction was significantly higher in AR (median 0.58%, IQR, 0.13%-1.68%) compared to non-AR (median 0.04%, IQR, 0.01%-0.11%, pc < 0.001). ROC analysis produced an area under the curve (AUC-ROC) of 0.86 (95% CI, 0.77-0.96). Defining samples with dd-cfDNA fraction ≥0.15% as AR yielded 78.5% sensitivity (95% CI, 60.7%-96.3%) and 76.9% specificity (95% CI, 71.1%-82.7%). Positive and negative predictive values were 25.1% (95% CI, 18.8%-31.5%) and 97.3% (95% CI, 95.1%-99.5%) respectively, calculated using the cohort AR prevalence of 9.0% (95% CI, 5.3%-12.8%) with adjustment for repeat samples. CONCLUSIONS This novel dd-cfDNA test detects AR in HTx recipients with good accuracy and holds promise as a noninvasive test for AR in HTx recipients.
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Affiliation(s)
- Paul J Kim
- UC San Diego Health, San Diego, California
| | | | - Alfonso Siu
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Omar Wever Pinzon
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Eric Adler
- UC San Diego Health, San Diego, California
| | | | | | | | | | | | | | | | | | | | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
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7
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Amadio JM, Rodenas-Alesina E, Superina S, Kozuszko S, Tsang K, Simard A, Aleksova N, Kobulnik J, Fan CPS, Wijeysundera HC, Ross HJ, McDonald MA, Duero Posada JG, Moayedi Y. Sparing the Prod: Providing an Alternative to Endomyocardial Biopsies With Noninvasive Surveillance After Heart Transplantation During COVID-19. CJC Open 2022; 4:479-487. [PMID: 35187463 PMCID: PMC8842090 DOI: 10.1016/j.cjco.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 02/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background The COVID-19 pandemic has reduced access to endomyocardial biopsy (EMB) rejection surveillance in heart transplant (HT) recipients. This study is the first in Canada to assess the role for noninvasive rejection surveillance in personalizing titration of immunosuppression and patient satisfaction post-HT. Methods In this mixed-methods prospective cohort study, adult HT recipients more than 6 months from HT had their routine EMBs replaced by noninvasive rejection surveillance with gene expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA) testing. Demographics, outcomes of noninvasive surveillance score, hospital admissions, patient satisfaction, and health status on the medical outcomes study 12-item short-form health survey (SF-12) were collected and analyzed, using t tests and χ2 tests. Thematic qualitative analysis was performed for open-ended responses. Results Among 90 patients, 31 (33%) were enrolled. A total of 36 combined GEP/dd-cfDNA tests were performed; 22 (61%) had negative results for both, 10 (27%) had positive GEP/negative dd-cfDNA results, 4 (11%) had negative GEP/positive dd-cfDNA results, and 0 were positive on both. All patients with a positive dd-cfDNA result (range: 0.19%-0.81%) underwent EMB with no significant cellular or antibody-mediated rejection. A total of 15 cases (42%) had immunosuppression reduction, and this increased to 55% in patients with negative concordant testing. Overall, patients' reported satisfaction was 90%, and on thematic analysis they were more satisfied, with less anxiety, during the noninvasive testing experience. Conclusions Noninvasive rejection surveillance was associated with the ability to lower immunosuppression, increase satisfaction, and reduce anxiety in HT recipients, minimizing exposure for patients and providers during a global pandemic.
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Affiliation(s)
- Jennifer M. Amadio
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Eduard Rodenas-Alesina
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Stefan Superina
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Stella Kozuszko
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Katherine Tsang
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anne Simard
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Natasha Aleksova
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jeremy Kobulnik
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Ted Rogers Computational Program, Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | | | - Heather J. Ross
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael A. McDonald
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Juan G. Duero Posada
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Yasbanoo Moayedi
- Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
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8
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Jiménez-Blanco Bravo M, Pérez-Gómez L, Hernández-Pérez FJ, Arellano-Serrano C, Torres-Sanabria M, Gómez-Bueno M, Oteo-Domínguez JF, Mingo-Santos S, Segovia-Cubero J. Lack of Usefulness of Donor-Derived Cell-Free DNA as a Biomarker for Cardiac Allograft Vasculopathy: A Prospective Study. Front Cardiovasc Med 2022; 9:856600. [PMID: 35463750 PMCID: PMC9019134 DOI: 10.3389/fcvm.2022.856600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/03/2022] [Indexed: 12/02/2022] Open
Abstract
Background Cardiac allograft vasculopathy (CAV) remains a major cause of morbidity and mortality among long-term heart transplant recipients. There is an unmet need for a non-invasive biomarker of CAV that could obviate the need to perform surveillance coronary angiograms in these patients. Our aim was to evaluate the performance of Donor-derived Cell Free DNA (dd-cfDNA) as a biomarker of CAV. Methods We prospectively measured dd-cfDNA levels in all patients undergoing routine coronary angiography >1 year after heart transplant at a single center. Endpoints included the association between dd-cfDNA levels and the presence CAV, according to several prespecified criteria. Results We included 94 heart transplant recipients, a median of 10.9 years after transplant. Coronary angiogram revealed CAV0, CAV1, CAV2, and CAV3 in 61, 19, 14, and 6% of patients, respectively. Comparison of dd-cfDNA levels in patients with CAV0 and CAV1–2–3 (primary end-point) did not show significant differences (0.92%, IQR 0.46–2.0 vs. 0.46%, IQR 0.075–1.5, p = 0.059), nor did the comparison between patients with stable CAV (no new coronary lesions since previous angiogram, n = 77) and progressive CAV (n = 17); dd-cfDNA values 0.735% (IQR 0.195–2.0) vs. 0.9% (IQR 0.12–1.8), p = 0.76. However, we found an association between NTproBNP levels and CAV degree (p = 0.017). Dd-cfDNA levels did not correlate with NTproBNP (ρ = −0.095). Conclusion In this study, dd-cfDNA did not perform as a useful biomarker to avoid surveillance coronary angiograms for CAV diagnosis. Clinical Trial Notation Potential Role of Donor-derived Cell Free DNA as a Biomarker in Cardiac Allograft Vasculopathy, NCT 04791852.
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Affiliation(s)
- Marta Jiménez-Blanco Bravo
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Hospital Universitario Ramón y Cajal, Madrid, Spain
- Centro de Investigación Biomédica en Red CIBER-CV, Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: Marta Jiménez-Blanco Bravo,
| | - Laura Pérez-Gómez
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Centro de Investigación Biomédica en Red CIBER-CV, Instituto de Salud Carlos III, Madrid, Spain
| | | | | | | | - Manuel Gómez-Bueno
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Centro de Investigación Biomédica en Red CIBER-CV, Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Javier Segovia-Cubero
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Centro de Investigación Biomédica en Red CIBER-CV, Instituto de Salud Carlos III, Madrid, Spain
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9
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Zhou L, Wolfson A, Vaidya AS. Noninvasive methods to reduce cardiac complications postheart transplant. Curr Opin Organ Transplant 2022; 27:45-51. [PMID: 34907978 DOI: 10.1097/mot.0000000000000953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Long-term success of heart transplantation is limited by allograft rejection and cardiac allograft vasculopathy (CAV). Classic management has relied on frequent invasive testing to screen for early features of rejection and CAV to allow for early treatment. In this review, we discuss new developments in the screening and prevention of allograft rejection and CAV. RECENT FINDINGS Newer noninvasive screening techniques show excellent sensitivity and specificity for the detection of clinically significant rejection. New biomarkers and treatment targets continue to be identified and await further studies regarding their utility in preventing allograft vasculopathy. SUMMARY Noninvasive imaging and biomarker testing continue to show promise as alternatives to invasive testing for allograft rejection. Continued validation of their effectiveness may lead to new surveillance protocols with reduced frequency of invasive testing. Furthermore, these noninvasive methods will allow for more personalized strategies to reduce the complications of long-term immunosuppression whereas continuing the decline in the overall rate of allograft rejection.
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Affiliation(s)
- Leon Zhou
- Department of Cardiology, Keck School of Medicine, Los Angeles, California, USA
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Coglianese E, Potena L. Markers of graft injury and the conundrum of racial disparities in outcomes after heart transplantation: early insights for long term outcomes. J Heart Lung Transplant 2022; 41:859-860. [DOI: 10.1016/j.healun.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 11/17/2022] Open
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11
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Kewcharoen J, Kim J, Cummings MB, Leitner KB, Suzuki EMB, Banerjee D, Lum CJ. Initiation of noninvasive surveillance for allograft rejection in heart transplant patients > 1 year after transplant. Clin Transplant 2021; 36:e14548. [PMID: 34843112 DOI: 10.1111/ctr.14548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 11/15/2021] [Accepted: 11/18/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Gene expression profiling (GEP) and donor-derived, cell-free DNA (dd-cfDNA) measurement are alternative methods to endomyocardial biopsy (EMB) to monitor for rejection following heart transplantation. We aim to describe our use of GEP and dd-cfDNA in heart transplant recipients > 1-year post-transplantation. METHODS This is a single-center, retrospective study in post-transplant recipients. For patients who were > 1-year post-transplantation and deemed to be at elevated clinical risk for rejection, we collected both GEP and dd-cfDNA every 3 months. Baseline characteristics including GEP, dd-cfDNA levels, rejection episodes, and number of biopsies were obtained. RESULTS Since July 2019, there were 18 patients being followed with GEP and dd-cfDNA who were > 1-year post-transplantation. Nine EMBs had been performed in seven patients due to as follows; three due to elevated GEP ({greater than or equal to} 34), one due to elevated dd-cfDNA ({greater than or equal to} .20%), two due to elevations of both GEP and dd-cfDNA, two due to clinical rejection and one to follow up a post rejection episode. One of the two biopsies due to elevations of both GEP and dd-cfDNA showed acute cellular rejection grade 2R. None of the biopsies due to either an elevation in the GEP or dd-cfDNA revealed any significant rejection. CONCLUSION In this study, the use of both GEP and dd-cfDNA led to an increased number of EMB in patients > 1-year post-transplantation. Further studies are needed to validate these findings and evaluate long-term consequences of these diagnostic tests in this population.
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Affiliation(s)
- Jakrin Kewcharoen
- University of Hawaii Internal Medicine Residency Program (UHIMRP), Honolulu, Hawaii, USA
| | - Jean Kim
- University of Hawaii Internal Medicine Residency Program (UHIMRP), Honolulu, Hawaii, USA
| | - Mandi B Cummings
- Queen's Heart Institute, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Katie B Leitner
- Queen's Heart Institute, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Erin M B Suzuki
- Queen's Heart Institute, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Dipanjan Banerjee
- Queen's Heart Institute, Queen's Medical Center, Honolulu, Hawaii, USA.,University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, USA
| | - Corey J Lum
- Queen's Heart Institute, Queen's Medical Center, Honolulu, Hawaii, USA.,University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, USA
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12
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Coniglio AC, Patel CB, Kittleson M, Schlendorf K, Schroder JN, DeVore AD. Innovations in Heart Transplantation: A Review. J Card Fail 2021; 28:467-476. [PMID: 34752907 DOI: 10.1016/j.cardfail.2021.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 01/15/2023]
Abstract
Advanced heart failure affects tens of thousands of people in the United States alone with high morbidity and mortality. Cardiac transplantation offers the best treatment strategy but has been historically limited by donor availability. Recently, there have been significant advances in organ allocation, donor-recipient matching, organ preservation and expansion of the donor pool. The current heart allocation system prioritizes the sickest patients to minimize waitlist mortality. Advances in donor organ selection including predicted heart mass calculations and more sophisticated antibody detection methods for allosensitized patients offer more effective matching of donors and recipients. Innovations in organ preservation such as with organ preservation systems have geographically widened the donor pool. The use of hepatitis C donors is possible with the advent of effective direct-acting antiviral agents to cure donor-transmitted hepatitis C. Finally, further expansion of the donor pool is occurring with the utilization of higher-risk donors with advanced age, medical comorbidities, and left ventricular dysfunction and advances in donation after circulatory death. This review provides an update on the new technologies and transplantation strategies that serve to widen the donor pool and more effectively match donors and recipients so that heart transplant candidates may derive the best outcomes from heart transplantation.
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Affiliation(s)
- Amanda C Coniglio
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Chetan B Patel
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | | | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Adam D DeVore
- Department of Medicine, Duke University School of Medicine, Durham, NC.
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13
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Burke RM, Dale BL, Dholakia S. The NLRP3 Inflammasome: Relevance in Solid Organ Transplantation. Int J Mol Sci 2021; 22:ijms221910721. [PMID: 34639062 PMCID: PMC8509131 DOI: 10.3390/ijms221910721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 02/06/2023] Open
Abstract
The NOD, LRR, and pyrin domain-containing 3 (NLRP3) protein has been established as a central component of the inflammasome and regulates the inflammatory response to a myriad of environmental, microbial, and endogenous danger stimuli. Assembly of the NLRP3 inflammasome results in the cleavage and activation of caspase-1, in turn causing release of the pro-inflammatory interleukins 1-beta and 18. This activation response, while crucial to coordinated innate immune defense, can be aberrantly activated by the likes of cell-free DNA, and cause significant autoimmune pathology. Complications of autoimmunity induced by aberrant NLRP3 inflammasome activation have a great degree of mechanistic crossover with alloimmune injury in solid organ transplant, and stratagems to neutralize NLRP3 inflammasome activation may prove beneficial in solid organ transplant management. This article reviews NLRP3 inflammasome biology and the pathology associated with its hyperactivation, as well as the connections between NLRP3 inflammasome activation and allograft homeostasis.
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Affiliation(s)
- Ryan M. Burke
- CareDx, Inc., Brisbane, CA 94080, USA; (R.M.B.); (B.L.D.)
| | | | - Shamik Dholakia
- CareDx, Inc., Brisbane, CA 94080, USA; (R.M.B.); (B.L.D.)
- Oxford Transplant Center, Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 7LD, UK
- Correspondence:
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14
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Amadio JM, Lafreniere-Roula M, McDonald M. Letter by Amadio et al Regarding Article, "Cell-Free DNA to Detect Heart Allograft Acute Rejection". Circulation 2021; 144:e196-e197. [PMID: 34491772 DOI: 10.1161/circulationaha.121.054333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jennifer M Amadio
- Ted Rogers Centre of Excellence in Heart Function (J.M.A., M.M.), Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Myriam Lafreniere-Roula
- Ted Rogers Computational Program, Centre of Excellence in Heart Function (M.L.-R.), Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Michael McDonald
- Ted Rogers Centre of Excellence in Heart Function (J.M.A., M.M.), Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
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15
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Abstract
Despite the overall success of heart transplantation as a definitive treatment for endstage heart failure, cardiac allograft rejection remains an important cause of morbidity and mortality. Endomyocardial biopsy has been the standard of care for rejection monitoring, but is associated with several diagnostic limitations and serious procedural complications. The use of molecular diagnostics has emerged over the past decade as a tool to potentially circumvent some of these limitations. We present an update on novel molecular approaches to detecting transplant rejection, focusing on 4 categories: microarray technology, gene expression profiling, cell-free DNA and microRNA.
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Affiliation(s)
- Lillian Benck
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute
| | - Takuma Sato
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Jon Kobashigawa
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute
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