Correlation of Blood Gene Expression (TruGraf Liver) With Liver Biopsy in Pediatric Liver Transplant Recipients
Conditions: Liver Transplant; Complications, Liver Failure, Acute
Sponsor: Children's Mercy Hospital Kansas City

SHORT TITLE: TruGraf Gene Expression Pediatric LTx 
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PROTOCOL TITLE:  
Correlation of blood gene expression (TruGraf Liver) with liver biopsy in pediatric liver 
transplant recipients 
 
PRINCIPAL INVESTIGATOR: 
Name: Ryan Fischer 
Department: Pediatrics, Division of Gastroenterology 
Phone: Office (816) 302-3410 | Cell (402) 680-8354 
Email Address: rtfischer@cmh.edu 
 
IND/IDE NUMBER:  
N/A 
 
VERSION NUMBER/DATE: 
Version 1.0  
03JAN2023 
 
REVISION HISTORY 
 
Revision 
# 
Version Date 
Summary of Changes 
Consent 
Change? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

SHORT TITLE: TruGraf Gene Expression Pediatric LTx 
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Table of Contents 
STUDY INFORMATION 
1.0 Study Summary 
2.0 Objectives 
3.0 Background 
4.0 Study Endpoints 
5.0 Study Design 
6.0 Study Interventions 
PARTICIPANT MANAGEMENT 
7.0 Inclusion and Exclusion Criteria 
8.0 Local Number of Participants 
9.0 Screening and Recruitment Methods 
10.0 Surveys and Psychometric Testing 
11.0 Additional Study Activities 
12.0 Follow-Up 
13.0 Genetic Analysis Information 
14.0 Sharing of Results with Participants 
15.0 Risks to Participants 
16.0 Potential Benefits 
17.0 Investigator Assessment of Risk/Benefits Ratio 
18.0 Payment, Reimbursement and Tangible Property Provided to Participants 
19.0 Compensation for Research-Related Injury 
20.0 Economic Burden to Participants 
21.0 Parental Permission and Adult Consent Process 
22.0 Assent of Pediatric Participants 
23.0 HIPAA and Confidentiality 
24.0 Provisions to Protect the Privacy Interests of Participants 
25.0 Withdrawal of Participants 
DATA MANAGEMENT 
26.0 Data Collection 
27.0 Adverse Events and Unanticipated Problems 
28.0 Statistical Analysis 
29.0 Data and Specimen Management 

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30.0 Storage/Banking of Data and Specimens for Future Research 
31.0 Provisions to Monitor the Data to Ensure the Safety of Participants 
DATA MANAGEMENT 
32.0 Settings and Locations 
33.0 Multi-Site Research 
34.0 International Research 
ADDENDUMS 
Addendum A: Waiver of Documentation of Permission/Consent 
Addendum B: Waiver/Alteration of Permission/Assent/Consent 
Addendum C: Non-English Speaking Participants 
Addendum D: Surrogate Decision Maker Consent 
Addendum E: Waiver/Alteration of HIPAA Authorization 
 
 
 

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STUDY INFORMATION 
1.0 
Study Summary* 
This study is an investigator-initiated, prospective, single-cohort trial to assess the ability 
of the TruGraf® Liver gene expression panel (GEP) to predict rejection in pediatric liver 
transplant recipients undergoing surveillance and for-cause liver biopsy.  
 
2.0 
Objectives* 
2.1 
Purpose, specific aims or objectives:  To evaluate the performance of the 
blood-based TruGraf® Liver GEP to accurately diagnose rejection, confirmed by 
surveillance or for-cause liver biopsy.  Additional objectives include comparison 
of GEP to non-rejection injury (e.g., infection) found on biopsy as well as changes 
in the GEP during rejection treatment and follow-up. 
2.2 
Hypothesis: TruGraf® Liver GEP will correlate with histologic evidence of 
quiescence or rejection in liver biopsies from a pediatric liver transplant 
population. 
 
3.0 
Background* 
While liver transplantation is a life-saving measure for both children and adults 
with end-stage liver disease, the transplant recipient is at lifelong risk of liver 
transplant rejection and possible loss of the transplanted organ. 
Immunosuppressive medications are used to prevent unwanted immune activity 
against the transplanted organ. However, the use of immunosuppression (IS) is a 
constant balancing act. Too much IS risks infection, side effects of medication 
(e.g., kidney injury) or the development of some cancers. Too little, and the 
patient’s immune system can reject the transplanted organ. Unfortunately, 
available serum liver enzyme tests (e.g., alanine aminotransferase or ALT, 
aspartate aminotransferase or AST, gamma-glutamyl transferase or GGT) are not 
a reliable indicator of rejection in the pediatric liver transplant recipient (1). 
Elevated enzymes are often associated with rejection, but they may also result 
from other liver stressors including infection and medication effect. Equally 
concerning, patients may have active rejection with otherwise normal enzyme 
levels. 
Anti-allograft immune activity or quiescence can only be defined by 
histopathologic evaluation of a liver biopsy specimen. The Rejection Activity 
Index (RAI) measures—on a scale of 0-3 for each category—the degree of portal 
inflammation, bile duct injury, and venous endothelial damage seen on liver 
biopsy (2). Thus, the RAI score can range from 0 (no signs of rejection) to 9 (the 
most severe rejection). In general, scores of 1-2 are considered “indeterminate” 
with lower risk of consequential rejection. Scores of 3 or greater are typical of 
rejection, and programs usually increase or adjust IS strategies in these patients. 

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Treatment can include high-dose steroids or biologic agents that predispose 
patients to infection and medication side effects. While liver biopsy is often 
obtained in patients with elevated AST, ALT, GGT, etc. to rule out rejection, these 
enzymes may be elevated in other conditions described above. Conversely, 
transplant recipients may have rejection without elevated liver enzymes, and 
programs (including ours) often obtain “surveillance” biopsies at regular 
intervals to ensure immune quiescence.  
Surveillance biopsies in the pediatric population have shown an association with 
reduced IS requirements, significantly fewer rejection episodes, and an 
association with superior allograft and patient survival (3). Yet, these invasive 
procedures are costly and carry risk to the patient and allograft. The Liver Care 
Center at Children’s Mercy performs surveillance biopsies on all pediatric liver 
transplant recipients bi-annually until they are transitioned into an adult 
program. The estimated cost of surveillance biopsy ranges from $1,500 to $3,000 
(4), not including additional hospital charges and miscellaneous fees. While the 
biopsies are performed with the utmost care using ultrasound guidance, 
significant bleeding (and even death) can complicate the procedure. 
Utilizing the TruGraf® Liver GEP (Transplant Genomics, Inc. (TGI); Lenexa, KS) as a 
“liquid biopsy” may offer a non-invasive alternative to the surveillance biopsy 
and/or for-cause liver biopsy. The test does not require liver tissue, and instead 
is run on a routinely obtained blood sample. This may provide opportunity for 
more frequent monitoring of liver injury and may aid in IS management. If the 
GEP correlates with and discriminates between biopsy results associated with 
rejection and those associated with quiescence, there is opportunity to reduce 
risk to liver transplant recipients, carefully personalize medication regimens, and 
produce a cost-savings. 
References 
1.  Rocque B, et al. “Clinical Value of Surveillance Biopsies in Pediatric Liver 
Transplantation.” Liver Transplant (2022). 
2.  Demetris et al. “Banff Schema for Grading Liver Allograft Rejection: An 
International Consensus Document.” Hepatology (1997).  
3. Squires JE, Demetris AJ. “Surveillance Biopsies in Pediatric Liver 
Transplantation: Is the Juice Worth the Squeeze?” Liver Transplantation (2022). 
4.  Allen AM, et al. “Healthcare Cost and Utilization in Nonalcoholic Fatty Liver 
Disease: Real-World Data From a Large U.S. Claims Database.” Hepatology 
(2018). 
 
4.0 
Study Endpoints 

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4.1 
Primary endpoint will be the correlation of the TruGraf® Liver GEP with 
rejection activity index (RAI) on surveillance and for-cause biopsy. 
4.2 
Secondary endpoints will include  
A) a comparison of the GEP to non-rejection injury (e.g., infection) found 
on biopsy 
B) utility of the GEP for monitoring liver injury (i.e., as treatment is 
weaned, does the GEP return to a non-rejection correlate). 
 
5.0 
Study Design* 
5.1 
Study Design: This will be a prospective cohort study.  
5.2 
All pediatric liver transplant recipients undergoing surveillance or for-
cause liver biopsy will be approached for inclusion in the study.  For those 
consented, study staff will collect medical history, demographics, height and 
weight, laboratory results, liver-related medical information, and up to 4 blood 
samples.  The initial blood sample will be obtained at standard of care labs 
performed the week prior to liver biopsy or at the time of biopsy. Additional 
blood samples will be collected at standard of care blood draws at weeks 8-12, 
20-24, and 30-36 and stored for potential GEP analysis. If subjects do not get a 
SOC blood draw at these time points we will get a sample at their nearest SOC 
draw.  We will not have a blood draw done just for research. The PI will review 
blood draw amounts to ensure that they do not exceed NIH blood draw 
limitations. If they do, the blood used for research will not be drawn.  Blood 
samples will be used to evaluate the TruGraf® Liver GEP (see section 6.0 for 
more info on TruGraf® GEP). 
5.3 
Table of Events:  
The only event on this study that is not standard of care are informed consent at start of study 
and the collection of additional blood at weeks 8-12, 20-24, and 30-36 for GEP analysis that are 
done at the same time as standard of care blood draws. 
 
6.0 
Study Interventions/Investigational Agent* 
6.1  
Description: This study will evaluate the TruGraf® Liver GEP, a panel that 
measures messenger RNA levels of 120 genes that are differentially expressed in 
transplant quiescence and subclinical rejection.  Blood samples will be used to 
run the GEP and data as outlined in section 26.1 obtained from subjects chart 
will be used with GEP results to evaluate the GEP.  
 
6.2 
Drugs or Biologics:  N/A 
 

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6.3 
Medical Devices. The blood test being studied is not of substantial 
importance in diagnosing, curing, mitigating or treating disease, or otherwise 
preventing impairment of human health and doesn’t present a potential form 
serious risk to the health safety or welfare of the participant. The gold standard 
for diagnosing liver transplant rejection is biopsy, which is being done as part of 
standard of care outside of the study and the results of this blood test will not be 
used to direct care.  As it is a blood test and not an implant it does not meet any 
of the other criteria in the regulations so does not require  an IDE/HDE. There is 
no risk to the subject outside of the general risk of phlebotomy which is being 
done for standard of care. The de-identified blood samples will be sent to TGI and 
the TruGraf Liver GEP test will be done at their laboratory.  None of the 
investigators will store, handle or administer the blood test. 
Device Name 
FDA Approval Status and Use in this 
Study 
IDE/HDE applicability 
 TruGraf® Liver GEP 
 Other 
Exempt from IDE requirements 
 
6.4 
Behavioral Intervention: N/A 
 
 
PARTICIPANT MANAGEMENT 
7.0 
Inclusion and Exclusion Criteria* 
7.1 
Eligibility Criteria:  
Inclusion Criteria 
• All liver transplant patients at least 1 year of age and less than 18 years of 
age undergoing surveillance or for-cause liver biopsy 
Exclusion Criteria 
• Non-English, non-Spanish Speaking 
 
7.2 
Equitable Selection:  This study will promote diversity by offering 
enrollment to nearly every patient presenting to the Liver Care Center at 
Children’s Mercy Kansas City for post-transplant care. This study will include 
consent forms written in both English and Spanish. We will attempt to use the 
short form if there is a patient whose primary language is not Spanish or English 
and have a certified translator present to translate the consent form. 
7.3 
Vulnerable Populations: Check any vulnerable populations that are being 
targeted for enrollment into the study: (Members of the following populations 
may not be included as participants in the research unless selected here.) 

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☒ Children/Minors (under 7 years of age) 
☒ Children/Minors (7-17 years of age) 
☐ Neonates (infants less than 30 days old) 
☐ Neonates of Uncertain Viability (infants 
less than 30 days old) 
☐ Non-Viable Neonates (infants less than 
30 days old) 
☐ Wards of the State 
☐ Fetuses 
☐ Pregnant Women  
☐ Adults with impaired decision-making 
capacity         
☐ CM Employees 
☐ CM Students/Residents/ Fellows 
☐ Economically or Educationally 
Disadvantaged Persons 
☐ Prisoners 
 
 
• We will obtain parental permission and (where applicable) the assent of the 
child/subject. The study presents no more than minimal risk as blood draw 
for GEP will be done at the same time as standard of care laboratory studies 
and will adhere to daily/weekly blood draw limits. Potential participants will 
be given ample time to ask questions and it will be iterated that participation 
is optional and will not affect clinical care. 
 
8.0 
Local Number of Participants 
8.1 
Our enrollment goal will be 25 patients. We will enroll at least 8 
patients obtaining biopsy “for cause” (higher risk of rejection) and at least 
8 surveillance biopsy patients.  
 
Total 
Sub-group 
“For Cause” 
Sub-group 
“Surveillance” 
Enrollment Goal: 
Number of participants to be enrolled = the 
number of participants to be consented. 
25 
At least 8 
At least 8 
 
9.0 
Identification and Recruitment of Potential Participants* 
9.1 
Identification of Potential Participants:   
How will participants be identified? (Check all that apply) 
 
☒ Chart reviews  
 
☒ By their treating physician who will then provide the study team’s contact 
information to the potential participant/family 

SHORT TITLE: Liver Transplant Gene Expression Profile 
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☒ By their treating physician who will obtain patient/family permission to share 
contact information with the study team 
☐ Self-refer in response to IRB approved advertisements or websites  
☐ Through Cerner or other CM sources (e.g. databases, billing records, 
pathology reports, admission logs, etc.) May involve access of records by 
individuals not involved in the patient’s care. 
☐ List of candidates provided through the Data Report Request Form  
☐ Registry of individuals interested in research opportunities   
☐ Past participant list 
☐ Participants will roll-over from another research study: Study # 
☐ Other:  
 
9.2 
Pre-Screening prior to HIPAA Authorization 
Will any of the identification methods checked above involve 
access to Protected Health Information (PHI) prior to obtaining 
HIPAA Authorization? 
☒ Yes 
 
☐ No 
• If yes, a “Partial Waiver of HIPAA Authorization” is required.  Be sure to 
make this selection in the “HIPAA & Confidentiality” section below and 
complete Addendum E: Waiver/Alteration of HIPAA Authorization 
 
9.3 
Recruitment of Potential Participants:   
• Patients will be recruited from the Pediatric Liver Transplant Program 
clinic. The clinic cares for more than 100 pediatric recipients of liver 
transplant. Patients are seen in person in clinic on at least an annual 
basis. Patients undergo biopsy on a bi-annual schedule. An estimated 50 
liver biopsies are done for surveillance or for cause annually. Patients 
undergoing liver biopsy are scheduled at least 2-3 days in advance. This 
will allow adequate time for the transplant team to notify the physician 
and/or research team of the upcoming biopsy.  

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• A member of the study team will introduce the study to eligible 
subjects/families during a clinic visit or clinical phone call that is prior to 
liver biopsy. If this is not feasible, a member of the study team will call 
eligible families prior to liver biopsy and introduce to the study. 
 
10.0 Surveys and Psychometric Testing: 
11.0 Additional Study Activities 
15.0 Risks to Participants 
16.0 Potential Benefits