Abstract: Background: Routine follow-up of kidney transplant recipients (KTxR) is usu­ally carried oul by moniloring serum creatinine, proteinuria, immunosuppres­sive blood levels, polyomaviws vircmia, and donor-specific antibodies (DSA). Despite this, the allograft can be suffering a significan! T cell- or antibody-me­diated damage thal may only be detecled by perlorming an invasiva proce­dure such as a kidney biopsy. 11 would be o! the outmosl interest to have a non-invasive tesl to know the status o! the allografl. Recen! lechnological advances allow to de1ect the presence o! donor derived cell free DNA (dd· clDNA) circulaling in lhe recipienrs blood. Sorne sludies have related lhe per­cenlage ol dd?clDNA 10 alloimmune graft damage. Methods: The percenlage ol dd-clDNA (%dd-clDNA) was measured by lhe CE IVD approved AlloSeq tesl (CareDx) in 10 KTxR on 10/Dec/2021. Brietly, plasma was collecled in Slreck BCT tubes. cfDNA was extracted using the QiAamp Circulaling Nucleic Acid Kit. 202 SNP regions were amplified and sequenced in a MiSeq nexl genaration sequenc1ng (lllumlna). The fraction of donor-specific sequencas was calculated by a spacilically developed CareDx Software. The relalionship belween lhe %dd-cfDNA and lhe clinical siluation o! the recipients was explored. dd-cfDNA o! 3 palients was analyzed twice. Results: Median %dd?c1DNA was 0.51% (IQR 0.34%. 0.98%). 6 KTxR with stabla GFR and wi\hout DSA had %dd-clDNA between 0.22 and 0.51%. The patienl with lhe highest %dd-clDNA (1 .4%) was suffering and anlibody? rnerliated rejeclion. The only 01her value above 1% (1.1%) carne into a palien1 recovering from acute lubular necrosis of a dono, alter cardiac dealh on day 33 posHransplanlalion. A %dd-clDNA ol 0.94% related lo a KTxR at 19 days alter DBD lransplant. whereas a pa1ient with stable renal func­lion but wilh de novo DSA 11ad a %dd?c1DNA ol 0.81%, suggesling lhe presence o! subclinical anlibody-mediated damage. %dd-clDNA did nol related 10 eslimaled GFR (r - -0.201. p ?? 0.578). Samples repealed twice gave exaclly lhe same values. Concluslons: AlloSeq les! allows measuring %dd-cfDNA in a simple, non­invasive and reproducible way. %dd-clDNA relates to undeying allografl darnage thal cannol be deleclable by currenl monitoring methods such as sen.11n creatinine.

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