Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. X:X | DOI: 10.5507/bp.2025.016

Exploring acute cellular rejection in lung transplantation: insights from donor-derived cell-free DNA analysis

Andrea Zajacova1#, Majd Alkhouri1#, Miray Guney2, Goncalo Ferrao2, David Rezac3, Kristyna Vyskocilova1, Tereza Kotowski1, Alzbeta Dutkova1, Eliska Dvorackova4, Robert Lischke5, Libor Fila1, Jan Havlin5
1 Prague Lung Transplant Program, Department of Pneumology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
2 Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
3 7th Field Hospital of the Army of the Czech Republic, Hradec Kralove, Czechia
4 Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
5 Prague Lung Transplant Program, 3rd Department of Surgery, First Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
# These authors contributed equally to the work

Background: Acute cellular rejection (ACR) is a frequent complication following lung transplantation, yet standardized guidelines for ACR screening remain lacking. This study aimed to compare the current gold standard for ACR evaluation - histological assessment of transbronchial biopsies - with a novel biomarker for allograft monitoring: donor-derived cell-free DNA (dd-cfDNA). Specifically, we investigated whether total cell-free DNA (cfDNA) and both the absolute and percentage values of dd-cfDNA (dd-cfDNA and dd-cfDNA%) could provide valuable insights into detecting ACR and assessing allograft health.

Methods: Patients after bilateral lung transplantation between May 2021 and March 2024 were included. Clinically significant ACR cases (ACR+) were defined as samples with histological ACR grade ≥A2 or ACR grade A1 in patients who have received antirejection therapy due to symptoms, CT findings, or lung function decline. Samples with A0 or A1 rejection in clinically stable, untreated patients were classified as controls. Measurements of dd-cfDNA%, dd-cfDNA (cp/mL) and total cfDNA (cp/mL) were obtained at the time of biopsy and compared between cohorts.

Results: The median dd-cfDNA concentration was significantly higher in the ACR+ group (61.2 cp/mL, IQR: 38.7-114.1) compared to controls (25.8 cp/mL, IQR: 10.7-65.7; P=0.04). However, no significant differences were observed for dd-cfDNA% and cfDNA.

Conclusion: Dd-cfDNA shows promise as a valuable tool for ruling out ACR; however, further research is necessary in order to validate its clinical utility and optimize its implementation. Its negative predictive value supports dd-cfDNA as an effective screening tool for allograft health, nevertheless, further investigation is required.

Keywords: lung transplantation, acute cellular rejection, donor-derived cell-free DNA, biomarkers, non-invasive surveillance

Received: February 12, 2025; Revised: April 29, 2025; Accepted: May 6, 2025; Prepublished online: May 16, 2025 

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