absolute!quan-fica-on!of!gra3!derived!cell7free!dna( gcfdna...
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Absolute Quan-fica-on of Gra3 derived cell-‐free DNA (GcfDNA) early a3er Liver Transplanta-on (LTx) using droplet Digital PCR
J. Beck1, P. Kanzow2, J. Schmitz2, O. Kollmar3, M. Oellerich2, E. Schütz1. 1) Chronix Biomedical, Gö5ngen, Germany, 2) Dept. Clinical Chemistry, University Medicine, Gö5ngen, Germany, 3) TransplantaCon Surgery, University Medicine, Gö5ngen, Germany
Background: The diagnos,c value of GcfDNA as measure of gra8 integrity a8er LTx has been recently proven [1,2]. The yin and yang of using percentage values vs. absolute GcfDNA quan,fica,on is, nevertheless, under discussion [3]. Where the ra,o of gra8 to host cfDNA has analy,cal advantages by elimina,ng disturbing variables, such as DNA extrac,on efficiency, variabli,es in host cfDNA may obfuscate the view on the engra8ed organ. The early phase a8er LTx was used as model to interrogate whether the percentage or absolute plasma concentra,on of GcfDNA is a more valuable gra8 integrity measure. Methods: GcfDNA percentage was determined by droplet dPCR (BioRad) as described [1]. A synthe,c sequence of non-‐human origin (average length of cfDNA ) was spiked into 1mL plasma, and quan,fied with ddPCR a8er DNA extrac,on in one fluorescent channel. The total cfDNA was quan,fied using two combined human genomic dPCRs in the second channel as copies/mL (cp/mL). Total cfDNA was calculated using the spike-‐in without being extracted to assess the DNA extrac,on efficiency in each batch. GcfDNA concentra,on was defined as of the total cfDNA(cp/mL) x GcfDNA%. Plasma obtained during the first 10 days a8er LTx from 15 pa,ents (one split-‐LTx) was inves,gated. Results: Ten repeated extrac,ons of the same plasma pool from healthy volunteers yielded an average of 1069 diploid genomic cp/mL plasma with a CV of 7.5%. Of 185 samples six showed a low (<50%) extrac,on efficiency; the remainders had an average of 67%+9%. The total cfDNA was highly variable peaking at 6hr a8er reperfusion (3.9x105±2.0x105cp/mL) weaning to 1.3x105±0.9x105 cp/mL at day 10. The respec,ve GcfDNA was 3.1x105±1.8x105 cp/mL (6hr) and 1.5x103±0.9x103 cp/mL (day10). The correla,on between GcfDNA% and GcfDNA(cp/mL) values was weak (r=0.61;p<0.05). A comparison of the AUC (d1-‐d5) of AST with GcfDNA percentage and concentra,on showed a beeer associa,on with absolute GcfDNA (r=0.65;p<0.05) compared to percentages (r=0.31;p=0.27). The ini,al half life was 1.3d±0.6 for GcfDNA(cp/mL) and 2.9d±1.6 GcfDNA(%), compared to 2.6d±1.2 for AST. Conclusions: A robust and precise ddPCR method for absolute quan,fica,on of GcfDNA, was developed, combining the analy,cal advantages of gra8/host ra,o (e. g. elimina,ng possible bias from interferences), with a robust quan,fica,on of total cfDNA. The GcfDNA concentra,on seems beeer associated with AST-‐values early a8er LTX and showed a more rapid dynamics than %GcfDNA. Even though the ini,al post Tx phase, with highly variable amounts of total cfDNA, is par,cularly complicated, this method may also provide a beeer view on gra8 integrity in other situa,ons, where the host cfDNA is increased due to non-‐transplanta,on related causes. As to whether the clinical u,lity is improved compared to percentage values for stable pa,ents as well, is subject to further inves,ga,ons.
It has been shown is several studies that the quan,fica,on of gra8 derived circula,ng free DNA (GcfDNA) has the clinical poten,al for interroga,ng the integrity of the transplanted organ using this “liquid biopsy” approach [1,5]. We have shown that GcfDNA% is useful to assess the minimal required dosage of immunosuppressive drugs in the early post transplant phase [2]. However, the use of percentages can be misleading of non-‐transplant related circumstances lead to an increase of host cfDNA, over the amount that is usually observed in complica,on-‐free solid organ recipients. Furthermore the immediate early post engra8ment phase is complicated by the recovery from preserva,on-‐reperfusion injury, which can lead to extreme cfDNA concentra,ons. The minute amounts of cfDNA that can be extracted from plasma require careful control of extrac,on efficiency and analy,cal methods that yield precise measures with minimum sample input. The aim of this work was to establish a robust system for reliable quan,fica,on of GcfDNA expressed as absolute concentra,on [cp/mL], controlling the pre-‐analy,cal error and the comparison of diagnos,c use with the established GcfDNA percentage determina,on.
Pa-ents, Material and Methods Blood samples from pa,ents a8er liver (LTx), heart (HTx) and kidney (KTx) were drawn according to IRB approved protocols. 288 samples from 23 Ltx were included. For the cfDNA extrac,on inves,ga,ons pools from normal volunteers are used. EDTA-‐whole blood was drawn and processed within 4 hours and stored frozen at -‐80°C un,l extrac,on. For LTx pa,ents cfDNA tubes (9mL) Streck Inc. were used for a subset of draws. cfDNA Extrac-ons Before extrac,on all plasma samples were centrifuged at 4000 x g for 20 min at 4°C. Two cfDNA extrac,on methods: QIAamp Circula,ng Nucleic Acid Extrac,on Kit (QIAGEN), Roches High Pure Viral Extrac,on Large Volume (LV) Kit (ROCHE LV) were used to the manufacturers recommenda,ons. The LV Kit was also used with 1/3 and without the recommended carrier RNA. Extrac,ons were performed on the same plasma pool on three different days. Two different volumes were extracted with each kit: 2.5 mL and 5 mL for QIAGEN, 1mL and 2.5 mL for ROCHE LV. ddPCR were performed in triplicate for each extrac,on day. For the in-‐assay assessment of the extrac,on yield, an ar,ficial spike added to the plasma immediately before adding the protease/binding buffer. The spike consists of a non-‐human derived 320bp DNA that is prepared by PCR on the vector-‐cloned fragment. The product was stored in 1.4x106-‐fold concentra,on and was diluted freshly prior to extrac,on. ddPCR Assays All primers were purchased from Sigma-‐Aldrich and probes from MWG-‐Biotech Eurofins. ddPCRs were performed using a Bio-‐Rad QX100/QX200 (Bio-‐Rad) and data were analyzed using the QuantaSo8 version 1.5.38 so8ware (Bio-‐Rad) and exported to Excel for further calcula,ons. ddPCRs were performed in 1x ddPCR Supermix for Probes or EvaGreen mastermix as appropriate (Bio-‐Rad) Absolute cfDNA quan-fica-on For the quan,fica,on of absolute cfDNA two assays each targe,ng one single copy genomic locus were combined in one ddPCR (HEX channel) together with one assay targe,ng the ar,ficial spike product (FAM channel) GcfDNA [%] was measured as described elsewhere (1). The GcfDNA [cp/mL] was the calculated by mul,plying the GcfDNA [%] with the cfDNA [cp/mL] (Figure 1). 20 µl of the spike-‐dilu,on used for the respec,ve extrac,on were diluted to a final volume of 50 µL three ,mes and each dilu,on was measured in duplicates. ddPCRs contained 8 µL of extrac,on eluate or diluted spike control and 4 µL for samples drawn within the first 48hrs a8er surgery. cfDNA length asessment The absolute cfDNA values were corrected for the respec,ve spike recovery rate and the amplicon lengths of 98bp and 90bp, either assuming the size distribu,on as determined in cfDNA samples from healthy volunteers and pa,ents and the formula given in Figure 2 or using the cfDNA length index as determined by ddPCR (Figure 3). Simula,ons were computed for the range of observed size distribu,ons, where the PCR efficiency and the length index were calculated using R (10,000 simula,ons per size distribu,on, 1. peak 50 to 70%, second and third peak 5 to 45% to cover the observed range of the length index (3 to 30).
! Given the minute amounts of cell-‐free DNA, the absolute quan-fica-on of cfDNA requires at first careful control of the extrac-on stage. By adding and quan-fying a spiked-‐in ar-ficial DNA the extrac-on variability can be corrected.
! For accurate cfDNA quan-fica-on a triplex ddPCR assay was developed targe-ng two genomic loci and the spiked-‐in DNA. By combining two genomic targets higher numbers of posi-ve droplets are yielded, while keeping the needed sample volume low.
! Since PCR efficiency is lowered by the fragmenta-on of the cfDNA, a length correc-on factor was implemented. Individual differences in the cfDNA length distribu-on profiles introduce only small addi-onal bias, which may not be clinically relevant.
! The GcfDNA concentra-on seems be]er associated with AST-‐values early a3er LTX.
! The ini-al post Tx phase is characterized by highly variable and high amounts of total cfDNA, which declines with a approximate half life of 1.9 days.
! Absolute GcfDNA quan-fica-on may provide a be]er view on gra3 integrity in situa-ons, where the host cfDNA is increased due to non-‐transplanta-on related causes. Whether the clinical u-lity is improved compared to percentage values is subject to further inves-ga-ons.
Figure 1: Overview of different ddPCR assays applied for the exact absolute quan,fica,on of gra8 derived cell-‐free DNA.
Figure 2: Upper le8: Schema,c drawing of PCR efficiency decrease caused by random fragmenta,on of the template given that all fragments are of exactly the same size. Lower le8: Correc,on factor es,ma,on for lowered PCR efficiency based on the fragment length profile of cfDNA. Upper and lower right: Experimental data showing the effect of PCR efficiency correc,on based on amplicon and template lengths.
Figure 3: Agilent Bioanalyzer images (upper le8) were used to determine the percentage of molecules present in the shortest peak. Upper right: This percentage is highly nega,vely correlated with the frac,onal abundance of larger sized amplicons as determined in the length index ddPCR detailed in Figure 1. Lower right: Modeling of the PCR efficiency versus the length index and a mean amplicon size of 94 bp as used in the total cfDNA concentra,on ddPCR. The model can be used to correct the template length dependent decrease in PCR efficiency for any given experimentally determined length index.
Figure 4: Bland-‐Altman Plot showing the maximum devia,on between the absolute cfDNA values either corrected by the samples experimentally determined length index (n=141, range: 3.7 to 27.5) or by a mean length correc,on factor of 0.59. The 95% confidence interval indicates that the differences in cfDNA length profiles introduce an error of only 10%.
Figure 5: Comparison of different extrac,on kits with respect to spike recovery rate (upper panel) and cfDNA yield (middle panel). All extrac,ons were performed on the same plasma pool in triplicate and on three consecu,ve days, mean values and standard devia,ons over all extrac,ons are shown. Lower panel: cfDNA yields corrected for the spike recovery rate; no significant differences between the different extrac,on methods remained, proving the importance and feasibility to correct for extrac,on efficiency by means of a spiked-‐in control.
Table 1: Mul,variate correla,on of GcfDNA percentages and absolute GcfDNA concentra,on with clinical parameters. Aeributable to their higher dynamic range the absolute GcfDNA values are significantly correlated to the AST levels, while the percent GcfDNA that do not account for the total cfDNA content per mL of plasma are not. CIT = cold ischemia ,me, WIT = warm ischemia ,me, AST = aspartate aminotransferase
Figure 6: Absolute GcfDNA concentra,ons within the first eight days post surgery of 14 pa,ents were used to calculate the range demarcated in the figure. The absolute GcfDNA in the early post-‐Tx phase are highly variable spanning over nearly two powers of ten. Addi,onally shown is the absolute GcfDNA ,mecourse of a pa,ent who received a marginal donor organ (HELLP-‐liver). The GcfDNA levels of this pa,ent were low and the post opera,ve gra8 func,on was excellent, indica,on that early GcfDNA determina,ons are suitable to assess the gra8 quality of marginal donors.
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