Validation of donor fraction cell-free DNA with biopsy-proven cardiac allograft rejection in children and adults

Marc E. Richmond*, Shriprasad R. Deshpande, Steven D. Zangwill, David P. Bichell, Steven J. Kindel, William T. Mahle, Jacob N. Schroder, Mark A. Wigger, Kenneth R. Knecht, Elfriede Pahl, Nunzio A. Gaglianello, Mary A. Goetsch, Pippa Simpson, Mahua Dasgupta, Liyun Zhang, Paula E. North, Aoy Tomita-Mitchell, Michael E. Mitchell

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Objectives: Donor-specific cell-free DNA shows promise as a noninvasive marker for allograft rejection, but as yet has not been validated in both adult and pediatric recipients. The study objective was to validate donor fraction cell-free DNA as a noninvasive test to assess for risk of acute cellular rejection and antibody-mediated rejection after heart transplantation in pediatric and adult recipients. Methods: Pediatric and adult heart transplant recipients were enrolled from 7 participating sites and followed for 12 months or more with plasma samples collected immediately before all endomyocardial biopsies. Donor fraction cell-free DNA was extracted, and quantitative genotyping was performed. Blinded donor fraction cell-free DNA and clinical data were analyzed and compared with a previously determined threshold of 0.14%. Sensitivity, specificity, negative predictive value, positive predictive value, and receiver operating characteristic curves were calculated. Results: A total of 987 samples from 144 subjects were collected. After applying predefined clinical and technical exclusions, 745 samples from 130 subjects produced 54 rejection samples associated with the composite outcome of acute cellular rejection grade 2R or greater and pathologic antibody-mediated rejection 2 or greater and 323 healthy samples. For all participants, donor fraction cell-free DNA at a threshold of 0.14% had a sensitivity of 67%, a specificity of 79%, a positive predictive value of 34%, and a negative predictive value of 94% with an area under the curve of 0.78 for detecting rejection. When analyzed independently, these results held true for both pediatric and adult cohorts at the same threshold of 0.14% (negative predictive value 92% and 95%, respectively). Conclusions: Donor fraction cell-free DNA at a threshold of 0.14% can be used to assess for risk of rejection after heart transplantation in both pediatric and adult patients with excellent negative predictive value.

Original languageEnglish (US)
Pages (from-to)460-468.e2
JournalJournal of Thoracic and Cardiovascular Surgery
Issue number2
StatePublished - Feb 2023


  • cell-free DNA
  • endomyocardial biopsy
  • heart transplantation
  • pediatric heart transplantation
  • rejection

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Pulmonary and Respiratory Medicine
  • Surgery


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