Medical College of Wisconsin
CTSICores SearchResearch InformaticsREDCap

Validation of donor fraction cell-free DNA with biopsy-proven cardiac allograft rejection in children and adults. J Thorac Cardiovasc Surg 2023 Feb;165(2):460-468.e2



Pubmed ID


Pubmed Central ID




Scopus ID

2-s2.0-85130912386 (requires institutional sign-in at Scopus site)   1 Citation


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.

Author List

Richmond ME, Deshpande SR, Zangwill SD, Bichell DP, Kindel SJ, Mahle WT, Schroder JN, Wigger MA, Knecht KR, Pahl E, Gaglianello NA, Goetsch MA, Simpson P, Dasgupta M, Zhang L, North PE, Tomita-Mitchell A, Mitchell ME


Steven J. Kindel MD Associate Professor in the Pediatrics department at Medical College of Wisconsin
Paula E. North MD, PhD Professor in the Pathology department at Medical College of Wisconsin
Pippa M. Simpson PhD Adjunct Professor in the Pediatrics department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Cell-Free Nucleic Acids
Graft Rejection
Heart Transplantation
Predictive Value of Tests