Antibody-mediated Rejection Without Detectable Donor-specific Antibody Releases Donor-derived Cell-free DNA: Results From the Trifecta Study

Philip F Halloran, Jeff Reeve, Katelynn S Madill-Thomsen, Zachary Demko, Adam Prewett, Philippe Gauthier, Paul Billings, Christopher Lawrence, Dave Lowe, Luis G Hidalgo, the Trifecta Investigators, Philip F Halloran, Jeff Reeve, Katelynn S Madill-Thomsen, Zachary Demko, Adam Prewett, Philippe Gauthier, Paul Billings, Christopher Lawrence, Dave Lowe, Luis G Hidalgo, the Trifecta Investigators

Abstract

Background: Trifecta (ClinicalTrials.gov #NCT04239703) is a prospective trial defining relationships between donor-derived cell-free DNA (dd-cfDNA), donor-specific antibody (DSA), and molecular findings in kidney transplant biopsies. Previous analyses of double results showed dd-cfDNA was strongly associated with rejection-associated molecules in the biopsy. The present study analyzed the triple results in 280 biopsies, focusing on the question of dd-cfDNA levels in DSA-negative antibody-mediated rejection (AMR).

Methods: Molecular Microscope Diagnostic System biopsy testing was performed at Alberta Transplant Applied Genomics Centre, dd-cfDNA testing at Natera, Inc, and central HLA antibody testing at One Lambda Inc. Local DSA and histologic diagnoses were assigned per center standard-of-care.

Results: DSA was frequently negative in both molecular (56%) and histologic (51%) AMR. DSA-negative AMR had slightly less molecular AMR activity and histologic peritubular capillaritis than DSA-positive AMR. However, all AMRs-DSA-positive or -negative-showed elevated %dd-cfDNA. There was no association between dd-cfDNA and DSA in biopsies without rejection. In AMR, %dd-cfDNA ≥1.0 was more frequent (75%) than DSA positivity (44%). In logistic regression, dd-cfDNA percent (area under the curve [AUC] 0.85) or quantity (AUC 0.86) predicted molecular AMR better than DSA (AUC 0.66). However, the best predictions incorporated both dd-cfDNA and DSA, plus time posttransplant (AUC 0.88).

Conclusions: DSA-negative AMR has moderately decreased mean molecular and histologic AMR-associated features compared with DSA-positive AMR, though similarly elevated dd-cfDNA levels. In predicting AMR at the time of indication biopsies in this population, dd-cfDNA is superior to DSA, reflecting the prevalence of DSA-negative AMR, but the optimal predictions incorporated both dd-cfDNA and DSA.

Conflict of interest statement

P.F.H. reports having shares in Transcriptome Sciences Inc, a University of Alberta research company with an interest in molecular diagnostics, and is a consultant to Natera, Inc. K.S.M-T. is an employee of Transcriptome Sciences Inc. A.P., Z.D., P.G., and P.B. are all employees of Natera Inc., with stocks or options to buy stocks in the company. C.L. and D.L. are employees of One Lambda Inc. L.G.H. is a consultant for AdaptImmune Therapeutics. All remaining authors declare no conflicts of interest and have nothing to disclose.

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.

Figures

Graphical abstract
Graphical abstract
FIGURE 1.
FIGURE 1.
CONSORT flow diagram of the study design. CONSORT, Consolidated Standards Of Reporting Trials; dd-cfDNA, donor-derived cell-free DNA; DSA, donor-specific antibody; MMDx, Molecular Microscope Diagnostic System; OLI, One Lambda Inc.
FIGURE 2.
FIGURE 2.
Relationships between MMDx rejection categories, DSA and %dd-cfDNA. A, Boxplots showing the distribution of %dd-cfDNA values across central DSA categories. Boxes represent the interquartile ranges and horizontal lines the medians. B, DSA-negative category split into PRA-positive and PRA-negative categories. C, Venn diagram showing overlap of samples with Molecular Microscope Diagnostic System TCMR, ABMR, %dd-cfDNA ≥1, and DSA positivity. Samples with mixed rejection are in the intersection between AMR and TCMR. One hundred thirty-three of the 280 samples have none of the 4 features and are therefore outside of the ellipses. AMR, antibody-mediated rejection; dd-cfDNA, donor-derived cell-free DNA; DSA, donor-specific antibody; PRA, panel-reactive antibody; PRAHR, panel-reactive antibody–high risk; TCMR, T cell–mediated rejection.

References

    1. Huang E, Sethi S, Peng A, et al. . Early clinical experience using donor-derived cell-free DNA to detect rejection in kidney transplant recipients. Am J Transplant. 2019;19:1663–1670.
    1. Oellerich M, Shipkova M, Asendorf T, et al. . Absolute quantification of donor-derived cell-free DNA as a marker of rejection and graft injury in kidney transplantation: results from a prospective observational study. Am J Transplant. 2019;19:3087–3099.
    1. Bloom RD, Bromberg JS, Poggio ED, et al. . Cell-free DNA and active rejection in kidney allografts. J Am Soc Nephrol. 2017;28:2221–2232.
    1. Sigdel TK, Archila FA, Constantin T, et al. . Optimizing detection of kidney transplant injury by assessment of donor-derived cell-free DNA via massively multiplex PCR. J Clin Med. 2018;8:E19.
    1. Gupta G, Moinuddin I, Kamal L, et al. . Correlation of donor-derived cell-free DNA with histology and molecular diagnoses of kidney transplant biopsies. Transplantation. 2022;106:1061–1070.
    1. Agbor-Enoh S, Wang Y, Tunc I, et al. . Donor-derived cell-free DNA predicts allograft failure and mortality after lung transplantation. Ebiomedicine. 2019;40:541–553.
    1. Sharon E, Shi H, Kharbanda S, et al. . Quantification of transplant-derived circulating cell-free DNA in absence of a donor genotype. PLoS Comput Biol. 2017;13:e1005629.
    1. Thongprayoon C, Vaitla P, Craici IM, et al. . The use of donor-derived cell-free DNA for assessment of allograft rejection and injury status. J Clin Med. 2020;9:1480.
    1. Kataria A, Kumar D, Gupta G. Donor-derived cell-free DNA in solid-organ transplant diagnostics: indications, limitations, and future directions. Transplantation. 2021;105:1203–1211.
    1. Bloom RD, Augustine JJ. Beyond the biopsy: monitoring immune status in kidney recipients. Clin J Am Soc Nephrol. 2021;16:1413–1422.
    1. Agbor-Enoh S, Shah P, Tunc I, et al. ; GRAfT Investigators. Cell-free DNA to detect heart allograft acute rejection. Circulation. 2021;143:1184–1197.
    1. Hinojosa RJ, Chaffin K, Gillespie M, et al. . Donor-derived cell-free DNA May confirm real-time response to treatment of acute rejection in renal transplant recipients. Transplantation. 2019;103:e61.
    1. Filippone EJ, Farber JL. The monitoring of donor-derived cell-free DNA in kidney transplantation. Transplantation. 2021;105:509–516.
    1. Xiao H, Gao F, Pang Q, et al. . Diagnostic accuracy of donor-derived cell-free DNA in renal-allograft rejection: a meta-analysis. Transplantation. 2021;105:1303–1310.
    1. Bunnapradist S, Homkrailas P, Ahmed E, et al. . Using both the fraction and quantity of donor-derived cell-free DNA to detect kidney allograft rejection. J Am Soc Nephrol. 2021;32:2439–2441.
    1. Halloran PF, Reeve J, Madill-Thomsen KS, et al. ; Trifecta Investigators. Combining donor-derived cell-free DNA fraction and quantity to detect kidney transplant rejection using molecular diagnoses and histology as confirmation. Transplantation. [Epub ahead of print. June 29, 2022]. doi:10.1097/TP.0000000000004212
    1. Senev A, Coemans M, Lerut E, et al. . Histological picture of antibody-mediated rejection without donor-specific anti-HLA antibodies: clinical presentation and implications for outcome. Am J Transplant. 2019;19:763–780.
    1. Senev A, Callemeyn J, Lerut E, et al. . Histological picture of ABMR without HLA-DSA: temporal dynamics of effector mechanisms are relevant in disease reclassification. Am J Transplant. 2019;19:954–955.
    1. Callemeyn J, Lerut E, de Loor H, et al. . Transcriptional changes in kidney allografts with histology of antibody-mediated rejection without anti-HLA donor-specific antibodies. J Am Soc Nephrol. 2020;31:2168–2183.
    1. Halloran PF, Madill-Thomsen KS, Pon S, et al. ; INTERCOMEX Investigators. Molecular diagnosis of AMR with or without donor-specific antibody in kidney transplant biopsies: differences in timing and intensity but similar mechanisms and outcomes. Am J Transplan. 2022;22:1976–1991.
    1. Halloran PF, Reeve J, Madill-Thomsen KS, et al. ; Trifecta Investigators. The Trifecta study: comparing plasma levels of donor-derived cell-free DNA with the molecular phenotype of kidney transplant biopsies. J Am Soc Nephrol. 2022;33:387–400.
    1. Koenig A, Mezaache S, Callemeyn J, et al. . Missing self-induced activation of NK cells combines with non-complement-fixing donor-specific antibodies to accelerate kidney transplant loss in chronic antibody-mediated rejection. J Am Soc Nephrol. 2021;32:479–494.
    1. Koenig A, Chen CC, Marçais A, et al. . Missing self triggers NK cell-mediated chronic vascular rejection of solid organ transplants. Nat Commun. 2019;10:5350.
    1. Venner JM, Hidalgo LG, Famulski KS, et al. . The molecular landscape of antibody-mediated kidney transplant rejection: evidence for NK involvement through CD16a Fc receptors. Am J Transplant. 2015;15:1336–1348.
    1. Halloran PF, Venner JM, Madill-Thomsen KS, et al. . Review: the transcripts associated with organ allograft rejection. Am J Transplant. 2018;18:785–795.
    1. Halloran PF, Reeve J, Akalin E, et al. . Real time central assessment of kidney transplant indication biopsies by microarrays: the INTERCOMEX study. Am J Transplant. 2017;17:2851–2862.
    1. Reeve J, Böhmig GA, Eskandary F, et al. ; INTERCOMEX MMDx-Kidney Study Group. Generating automated kidney transplant biopsy reports combining molecular measurements with ensembles of machine learning classifiers. Am J Transplant. 2019;19:2719–2731.
    1. Madill-Thomsen K, Perkowska-Ptasińska A, Böhmig GA, et al. ; MMDx-Kidney Study Group. Discrepancy analysis comparing molecular and histology diagnoses in kidney transplant biopsies. Am J Transplant. 2020;20:1341–1350.
    1. Reeve J, Böhmig GA, Eskandary F, et al. ; MMDx-Kidney study group. Assessing rejection-related disease in kidney transplant biopsies based on archetypal analysis of molecular phenotypes. JCI Insight. 2017;2:94197.
    1. Kyeso Y, Bhalla A, Smith AP, et al. . Donor-derived cell-free DNA kinetics post-kidney transplant biopsy. Transplant Direct. 2021;7:e703.
    1. Altuğ Y, Liang N, Ram R, et al. . Analytical validation of a single-nucleotide polymorphism-based donor-derived cell-free DNA assay for detecting rejection in kidney transplant patients. Transplantation. 2019;103:2657–2665.
    1. Osmanodja B, Akifova A, Budde K, et al. . Absolute or relative quantification of donor-derived cell-free dna in kidney transplant recipients: case series. Transplant Direct. 2021;7:e778.
    1. The R Foundation. The R project for statistical computing. Available at . Accessed March 25, 2022.
    1. Halloran PF, Famulski KS, Chang J. A Probabilistic approach to histologic diagnosis of antibody-mediated rejection in kidney transplant biopsies. Am J Transplant. 2017;17:129–139.
    1. Callemeyn J, Senev A, Coemans M, et al. . Missing self-induced microvascular rejection of kidney allografts: a population-based study. J Am Soc Nephrol. 2021;32:2070–2082.
    1. Callemeyn J, Lamarthée B, Koenig A, et al. . Allorecognition and the spectrum of kidney transplant rejection. Kidney Int. 2022;101:692–710.
    1. Reed EF, Rao P, Zhang Z, et al. . Comprehensive assessment and standardization of solid phase multiplex-bead arrays for the detection of antibodies to HLA. Am J Transplant. 2013;13:1859–1870.
    1. Tambur AR, Campbell P, Claas FH, et al. . Sensitization in transplantation: assessment of risk (STAR) 2017 working group meeting report. Am J Transplant. 2018;18:1604–1614.
    1. Jackson AM, Wiebe C, Hickey MJ. The role of non-HLA antibodies in solid organ transplantation: a complex deliberation. Curr Opin Organ Transplant. 2020;25:536–542.
    1. Jackson AM, Delville M, Lamarthée B, et al. . Sensitization to endothelial cell antigens: unraveling the cause or effect paradox. Hum Immunol. 2019;80:614–620.
    1. Jackson AM, Kuperman MB, Montgomery RA. Multiple hyperacute rejections in the absence of detectable complement activation in a patient with endothelial cell reactive antibody. Am J Transplant. 2012;12:1643–1649.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner