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Absolute quantification of donor-derived cell-free DNA following pediatric and adult heart transplantation
Jens Böhmer1, Håkan Wåhlander2, Karin Tran-Lundmark3
1Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Pediatrics, Clinic Frankfurt-Höchst, Frankfurt, Germany.
Insights
Donor-derived cell-free DNA (dd-cfDNA) shows promise for monitoring heart transplant rejection. Absolute quantification of dd-cfDNA effectively detects symptomatic rejection, potentially reducing the need for invasive biopsies.
Area of Science:
- Cardiovascular Medicine
- Transplantation Immunology
- Molecular Diagnostics
Background:
- Endomyocardial biopsies (EMBs) are the standard for heart transplant rejection surveillance but are invasive and costly.
- Cell-free DNA (cfDNA) monitoring, particularly donor-derived cfDNA (dd-cfDNA), offers a less invasive alternative.
- Previous studies primarily focused on donor fraction (DF) of dd-cfDNA, limiting comprehensive evaluation.
Purpose of the Study:
- To evaluate the performance of absolute quantification of dd-cfDNA in detecting rejection after heart transplantation (HTx).
- To compare the diagnostic accuracy of dd-cfDNA with the donor fraction (DF) for rejection surveillance.
- To assess the utility of dd-cfDNA in identifying symptomatic rejection episodes.
Main Methods:
- Prospective enrollment of 94 heart transplant recipients across multiple centers.
- Concurrent collection of blood samples and endomyocardial biopsies (EMBs) for analysis.
- Quantification of dd-cfDNA using droplet digital PCR (ddPCR) and comparison with EMB results.
Main Results:
- A total of 1007 EMB and blood samples were analyzed.
- dd-cfDNA demonstrated good discrimination between rejection and quiescence (AUC 0.68) compared to DF (AUC 0.65).
- Absolute dd-cfDNA levels achieved an AUC of 0.87 for detecting symptomatic rejection, significantly outperforming DF (AUC 0.75).
Conclusions:
- Absolute quantification of dd-cfDNA is a highly effective method for monitoring heart transplant graft health.
- This approach shows superior performance in detecting symptomatic rejection compared to donor fraction analysis.
- dd-cfDNA monitoring may reduce the reliance on invasive EMBs and aid in understanding factors affecting cfDNA levels.
Objective:
Traditional rejection surveillance after heart transplantation (HTx) is based on endomyocardial biopsies (EMBs), which are invasive, expensive, and associated with complications. Monitoring using cell-free DNA (cfDNA) is promising, but most studies report only on the donor fraction (DF) as the percentage of donor-derived cfDNA (dd-cfDNA) relative to total cfDNA. We evaluated the performance of dd-cfDNA to detect rejection.
Methods:
HTx patients were prospectively enrolled in a multicenter study, and blood samples were collected concurrently with EMB. Dd-cfDNA was quantified using droplet digital PCR (ddPCR). Rejection was defined by EMB results and compared to nonrejection EMB. Patients with symptomatic rejection were studied as a subgroup, and test performance was determined using receiver operation characteristic analysis.
Results:
We included 94 patients (70 adults and 24 children), which resulted in 1007 EMB and blood samples. In 19 patients, there were 32 rejection episodes >14 days past HTx, with 15 of them being symptomatic. In receiver operation characteristic analysis, dd-cfDNA and DF could discriminate quiescence from rejection with an area under the curve (AUC) of 0.68 and 0.65, respectively. Dd-cDNA at a threshold of 25 copies/ml showed an AUC of 0.87 to detect symptomatic rejection, significantly better than DF (AUC of 0.75).
Conclusions:
dd-cfDNA found good discrimination between cardiac recipients with and without rejection. Absolute quantification of dd-cfDNA with ddPCR is a fast and effective method to monitor graft health. Analyzing absolute dd-cfDNA levels helps identify other factors, besides rejection, that may influence cfDNA levels, potentially reducing the need for EMB.
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