Trifecta-Heart cfDNA-MMDx Study

Official title

Trifecta-Heart cfDNA-MMDX Study: Comparing the DD-cfDNA Test to MMDx Microarray Test and Central HLA Antibody Test

Overview

Demonstrate the relationship between DD-cfDNA levels and HLA antibodies in blood transplant recipient and the Molecular Microscope® (MMDx) Diagnostic System results in indication and protocol biopsies from heart transplants.

Detailed description

The current standard for assessment of rejection in heart transplants is an endomyocardial biopsy (EMB) interpreted by histology according to ISHLT guidelines. This has considerable error rates, many due to the high disagreement among pathologists in assessing lesions and diagnoses. To address the unmet need for precision and accuracy, the Alberta Transplant Applied Genomics Centre (ATAGC, University of Alberta) has developed a new diagnostic system - the Molecular Microscope® Diagnostic System (MMDx), which uses microarrays to define the global gene expression features of rejection and injury. Now a new screening test is being introduced: the monitoring of donor-derived cell-free DNA (DD-cfDNA) released in the blood by the heart during rejection. The Natera Inc DD-cfDNA Prospera® test is based on the massively multiplex polymerase chain reaction that targets 13,392 single nucleotide polymorphisms and targeted sequences are quantified by Next Generation Sequencing. The Prospera® test has been done on kidney transplant recipients and detected "active rejection" and differentiated it from borderline rejection and no rejection. However, Prospera® test was not examined (the DD-cfDNA results) in heart transplant recipients. DD-cf-DNA test for heart transplants must now be calibrated against MMDx that is based on global gene expression, the new standard for biopsy interpretation. The present study will calibrate centrally measured (Natera Inc) DD-cfDNA levels obtained at the time of an indication or protocol biopsy against the MMDx measurements of T cell-mediated rejection (TCMR), antibody-mediated rejection (ABMR) and early and late tissue injury. The present study will compare DD-cfDNA and MMDx in 300 prospectively collected biopsies for clinical indications and protocol, and accompanying 600 blood samples, to calibrate the DD-cfDNA (Natera Inc.) levels against the MMDx biopsy diagnoses of TCMR, ABMR (and its stages), and acute (early) and chronic (late) injury, , as well as central assessment of HLA antibody (One Lambda) in 300 blood samples, interpreted centrally as donor specific antibody (DSA) based on the tissue typing results. Trifecta-Heart collected 690 biopsies, 679 cfDNA samples and 656 One Lambda samples so far. Due to a considerable interest from participation centers, this study aims to collect 300 more biopsies and corresponding blood samples. This study is an extension of the INTERHEART ClinicalTrials.gov Identifier: NCT02670408

Interventions

• Diagnostic test MMDx diagnostic test
  Microarray test of gene expression in heart biopsies
• Diagnostic test Prospera
  Donor derived cell-free DNA in patient blood
• Diagnostic test HLA antibody
  Centralized measurement of HLA antibodies in patient blood

Primary outcome measures

• Calibration of Prospera test for T cell-mediated rejection [Time frame: 18 months]
• Calibration of Prospera test for antibody-mediated rejection [Time frame: 18 months]
• Calibration of Prospera test for heart injury [Time frame: 18 month]
• Report calibrated Prospera test results for rejection [Time frame: 6 months]
• Report calibrated Prospera test results for heart injury [Time frame: 6 month]

Secondary outcome measures (3)

• Determine if Prospera blood test can replace heart biopsy test [Time frame: 6 month]
• Determine if Prospera blood test can replace follow up heart biopsy [Time frame: 6 month]
• Assessment of donor-specific antibody status [Time frame: 6 months]

Eligibility criteria

Inclusion criteria

• All heart transplant recipients undergoing a biopsy for clinical indications and protocol biopsies, as determined by their physician or surgeon, will be eligible to enroll in the study.
• Patients are enrolled based on standard of care biopsies, including surveillance biopsies in high-risk patients, with informed consent.

Exclusion criteria

• Patients will be excluded from the study if they decline participation
• Are unable to give informed consent.
• Recipients of multiple organs.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Observational model

Cohort

Study locations

United States · 6 centers

• Baptist Health Institute for Research and Innovation — Little Rock
• Tampa General Hospital, 409 Bayshore Blvd. — Tampa
• Columbia University Medical Center, Columbia Interventional Cardiovascular Care — West New York
• Montefiore Medical Center, 3319 Rochambeau Avenue, 2nd FL — The Bronx
• Annette C. and Harold C. Simmons Transplant Institute, BaylorScott&White Research Institut — Dallas
• Cardiovascular Medicine, University of Utah Health — Salt Lake City

Australia · 1 center

• Cardiac Transplantation Laboratory, The Victor Chang Cardiac Research Institute — Darlinghurst

Canada · 1 center

• Division of Cardiology, University of Alberta — Edmonton

Czechia · 1 center

• Institute for Clinical and Experimental Medicine - IKEM Videnska 1958/9 — Prague

Italy · 1 center

• Heart Failure and Heart Transplant Unit, University of Bologna — Bologna

Poland · 1 center

• Silesian Center for Heart Diseases (Ś!ąskie Centrum Chorób Serca w Zabrzu — Zabrze

Spain · 1 center

• Advanced Heart Failure Transplant Unit — A Coruña

Publications

• Madill-Thomsen KS, Halloran PF. Precision diagnostics in transplanted organs using microarray-assessed gene expression: concepts and technical methods of the Molecular Microscope(R) Diagnostic System (MMDx). Clin Sci (Lond). 2024 Jun 5;138(11):663-685. doi: 10.1042/CS20220530. PMID 38819301
• Halloran PF, Madill-Thomsen KS. Donor-derived Cell-free DNA: A Step Forward in the Quest for Transplant Truth. Transplantation. 2025 Jun 1;109(6):910-914. doi: 10.1097/TP.0000000000005332. Epub 2025 Jan 28. No abstract available. PMID 39883025
• Halloran PF, Reeve J, Mackova M, Madill-Thomsen KS, Demko Z, Olymbios M, Campbell P, Melenovsky V, Gong T, Hall S, Stehlik J. Comparing Plasma Donor-derived Cell-free DNA to Gene Expression in Endomyocardial Biopsies in the Trifecta-Heart Study. Transplantation. 2024 Sep 1;108(9):1931-1942. doi: 10.1097/TP.0000000000004986. Epub 2024 Aug 20. PMID 38538559
• Madill-Thomsen KS, Hidalgo LG, Mackova M, Campbell P, Demko Z, Felius J, Gong T, Hall S, Kim DH, Kuczaj A, Lowe D, Maliakkal N, Melenovsky V, Olympios M, Patel S, Prewett A, Przybylowski P, Sayer G, Stehlik J, Tseliou E, Uriel N, Halloran PF. Defining the relationships among four tests for assessing antibody-mediated rejection in heart transplants in a prospective, observational study. J Heart Lun PMID 41241034
• Madill-Thomsen KS, Hidalgo LG, Mackova M, Demko Z, Prewett A, Campbell P, Felius J, Gong T, Hall S, Kim DH, Kuczaj A, Lowe D, Maliakkal N, Melenovsky V, Olympios M, Patel S, Przybylowski P, Sayer G, Tseliou E, Uriel N, Stehlik J, Halloran PF; Trifecta-Heart Study Group. Comparing DSA-negative and DSA-positive antibody-mediated rejection in heart transplants: Results from the Trifecta-Heart study. PMID 41833593
• Halloran DPF, Madill-Thomsen KS, Biagini DG, Kaur N, Prewett A, Suresh N, Demko ZP, Bhorade S, Olympios M, Gauthier PT, Campbell PT, Gong T, Hall S, Kim DH, Kuczaj A, Przybylowski P, Melenovsky V, Patel SR, Sayer G, Stehlik J, Tseliou E, Uriel N, Mackova M; Trifecta-Heart Investigators. A two-threshold donor-derived cell-free DNA algorithm improves detection of molecular rejection in heart transpl PMID 42331120
• Halloran PF, Madill-Thomsen KS. The Molecular Microscope Diagnostic System: Assessment of Rejection and Injury in Heart Transplant Biopsies. Transplantation. 2023 Jan 1;107(1):27-44. doi: 10.1097/TP.0000000000004323. Epub 2022 Dec 8. PMID 36508644

Identifiers

NCT: NCT04707872 · ATAGC06

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗