Trifecta-Lung cfDNA-MMDx Study

Study Overview
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Brief Summary
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Demonstrate the relationship between dd-cfDNA levels and HLA antibodies in blood transplant recipient and Demonstrate the Molecular Microscope® (MMDx) Diagnostic System results in indication and protocol biopsies from lung transplants.

Detailed Description
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The current standard for assessment of rejection in lung transplants is a transbronchial biopsy (TBB) interpreted by histology according to International Society of Heart and Lung Transplantation (ISHLT) guidelines. This has considerable error rates, many due to the high disagreement among pathologists. There is a need for new methods of assessing TBBs. In addition, the emergence of blood donor-derived cell-free DNA (dd-cfDNA) measurement offers a new opportunity for screening for rejection. 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 genome-wide gene expression and interpret lung transplant rejection and injury ((chronic lung allograft dysfunction (CLAD) related changes)). Now a new screening test is being introduced: the monitoring of 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 lung transplant recipients. dd-cf-DNA test for lung 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-like) and tissue injury. The present study will compare dd-cfDNA and MMDx in 600 prospectively collected biopsies for clinical indications and protocol, and accompanying 1800 blood samples, to calibrate the dd-cfDNA (Natera Inc.) levels against the MMDx biopsy diagnoses of TCMR, ABMR-like (and its stages), and injury, as well as central assessment of Human Leukocyte Antibody (HLA) antibody (One Lambda), interpreted centrally as donor specific antibody (DSA) based on the tissue typing results. This study is an extension of the INTERLUNG ClinicalTrials.gov identifier: NCT02812290

Official Title
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Trifecta-Lung cfDNA-MMDx Study: Comparing the Dd-cfDNA Test to MMDx Microarray Test and Central HLA Antibody Test

Conditions
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Lung Transplantation

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult, Older adult Exclusion Criteria: Patients will be excluded from the study if they decline participation Are unable to give informed consent. Recipients of multiple organs, cancer patients and pregnant women

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Calibration of Prospera® test for T cell mediated rejection | Set dd-cfDNA test cut-off values against the probability of T cell-mediated rejection in the biopsy as reported by MMDx. Calibration of dd-cfDNA test cut-off values against the probability of T cell-mediated rejection in the biopsy as reported by MMDx. | 18 months | 
| Calibration of Prospera® test for antibody-mediated rejection | Set dd-cfDNA test cut-off values against the probability of antibody-mediated rejection in the biopsy as reported by MMDx. | 18 months | 
| Calibration of Prospera® test for lung injury | Set dd-cfDNA test cut-off values against the probability of acute and chronic lung injury in the biopsy as reported by MMDx. | 18 months | 
| Report calibrated Prospera® test results for rejection | Report new dd-cfDNA test cut-off values for rejection | 6 months | 
| Report calibrated Prospera® test results for lung injury | Report new DD-cfDNA test cut-off values for lung injury | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Assessment of donor-specific antibody status | Record and compare the DSA status (positive or negative) based on centralized and local HLA antibody to histology diagnoses.. | 6 months | 
| .Estimate the false positive rate of dd-cfDNA for MMDx and histology in indication and protocol biopsies | Calculate the sensitivity and specificity of dd-cfDNA for MMDx and histology diagnoses. | 6 months | 
| Determine whether calibrated dd-cfDNA blood test will replace biopsies | Determine if dd-cfDNA test will avoid need for indication biopsy when transplant function deteriorates - yes or no. This will be based on the consensus between participating clinicians. | 6 months | 
| Determine whether calibrated dd-cfDNA blood test predicts the effect of treatment | Determine the values for dd-cfDNA for grades of response to treatment: no change, partial response, complete resolution. | 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Donor derived cfDNA, Gene expression, Lung transplant biopsy, Blood