无细胞游离 DNA 检测心脏移植物急性排斥反应
Cell-Free DNA to Detect Heart Allograft Acute Rejection.
机构信息
Genomic Research Alliance for Transplantation, Bethesda, MD (S.A.-E., P.S., I.T., S.H., E.F., K.S., M.E.R., S.S.N., H.K., U.F., A.B., A.M., K.B., Y.Y., M.K.J., C.M., G.J.B., H.A.V.).
Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD (S.A.-E., I.T., H.K., M.P., U.F., A.B., A.M., K.B., Y.Y., M.K.J., H.A.V.).
出版信息
Circulation. 2021 Mar 23;143(12):1184-1197. doi: 10.1161/CIRCULATIONAHA.120.049098. Epub 2021 Jan 13.
BACKGROUND
After heart transplantation, endomyocardial biopsy (EMBx) is used to monitor for acute rejection (AR). Unfortunately, EMBx is invasive, and its conventional histological interpretation has limitations. This is a validation study to assess the performance of a sensitive blood biomarker-percent donor-derived cell-free DNA (%ddcfDNA)-for detection of AR in cardiac transplant recipients.
METHODS
This multicenter, prospective cohort study recruited heart transplant subjects and collected plasma samples contemporaneously with EMBx for %ddcfDNA measurement by shotgun sequencing. Histopathology data were collected to define AR, its 2 phenotypes (acute cellular rejection [ACR] and antibody-mediated rejection [AMR]), and controls without rejection. The primary analysis was to compare %ddcfDNA levels (median and interquartile range [IQR]) for AR, AMR, and ACR with controls and to determine %ddcfDNA test characteristics using receiver-operator characteristics analysis.
RESULTS
The study included 171 subjects with median posttransplant follow-up of 17.7 months (IQR, 12.1-23.6), with 1392 EMBx, and 1834 %ddcfDNA measures available for analysis. Median %ddcfDNA levels decayed after surgery to 0.13% (IQR, 0.03%-0.21%) by 28 days. Also, %ddcfDNA increased again with AR compared with control values (0.38% [IQR, 0.31-0.83%], versus 0.03% [IQR, 0.01-0.14%]; <0.001). The rise was detected 0.5 and 3.2 months before histopathologic diagnosis of ACR and AMR. The area under the receiver operator characteristic curve for AR was 0.92. A 0.25%ddcfDNA threshold had a negative predictive value for AR of 99% and would have safely eliminated 81% of EMBx. In addition, %ddcfDNA showed distinctive characteristics comparing AMR with ACR, including 5-fold higher levels (AMR ≥2, 1.68% [IQR, 0.49-2.79%] versus ACR grade ≥2R, 0.34% [IQR, 0.28-0.72%]), higher area under the receiver operator characteristic curve (0.95 versus 0.85), higher guanosine-cytosine content, and higher percentage of short ddcfDNA fragments.
CONCLUSIONS
We found that %ddcfDNA detected AR with a high area under the receiver operator characteristic curve and negative predictive value. Monitoring with ddcfDNA demonstrated excellent performance characteristics for both ACR and AMR and led to earlier detection than the EMBx-based monitoring. This study supports the use of %ddcfDNA to monitor for AR in patients with heart transplant and paves the way for a clinical utility study. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02423070.
背景
心脏移植后，心肌活检（EMBx）用于监测急性排斥反应（AR）。不幸的是，EMBx 具有侵入性，其常规组织学解释存在局限性。这是一项验证性研究，旨在评估一种敏感的血液生物标志物-供体游离 DNA 百分比（%ddcfDNA）-用于检测心脏移植受者 AR 的性能。
方法
这项多中心前瞻性队列研究招募了心脏移植患者，并在同时采集 EMBx 时收集血浆样本，通过 shotgun 测序测量%ddcfDNA。收集组织病理学数据以定义 AR、其 2 种表型（急性细胞排斥反应[ACR]和抗体介导的排斥反应[AMR]）和无排斥反应的对照。主要分析是比较 AR、AMR 和 ACR 与对照组的%ddcfDNA 水平（中位数和四分位距[IQR]），并使用接收者操作特征分析确定%ddcfDNA 检测特征。
结果
该研究纳入了 171 名中位术后随访时间为 17.7 个月（IQR，12.1-23.6）的患者，共进行了 1392 次 EMBx 和 1834 次%ddcfDNA 测量。手术后%ddcfDNA 水平中位数降至 0.13%（IQR，0.03%-0.21%），28 天后。此外，与对照值相比，%ddcfDNA 在 AR 时再次升高（0.38%[IQR，0.31-0.83%]，vs. 0.03%[IQR，0.01-0.14%]；<0.001）。ACR 和 AMR 的组织病理学诊断前 0.5 个月和 3.2 个月检测到升高。AR 的受试者工作特征曲线下面积为 0.92。0.25%ddcfDNA 阈值对 AR 的阴性预测值为 99%，可安全消除 81%的 EMBx。此外，%ddcfDNA 显示出与 AMR 相比，在 AR 中具有独特的特征，包括 5 倍更高的水平（AMR≥2，1.68%[IQR，0.49-2.79%]与 ACR 分级≥2R，0.34%[IQR，0.28-0.72%]），更高的受试者工作特征曲线下面积（0.95 对 0.85），更高的鸟嘌呤-胞嘧啶含量，以及更高比例的短 ddcfDNA 片段。
结论
我们发现%ddcfDNA 检测 AR 的受试者工作特征曲线下面积和阴性预测值较高。ddcfDNA 监测对 ACR 和 AMR 均具有出色的性能特征，并比基于 EMBx 的监测更早地检测到。这项研究支持使用%ddcfDNA 监测心脏移植患者的 AR，并为临床实用研究铺平了道路。注册：网址：https://www.clinicaltrials.gov；唯一标识符：NCT02423070。
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