Liver Transplantation
Conditions
Keywords
Liver transplantation, everolimus, calcineurin inhibitors, tacrolimus, renal function, MDRD formula, progression of fibrosis
Brief summary
This trial was designed to address important issues that impact recipients of liver allografts as well as clinicians, ie, renal function, reduction or discontinuation of tacrolimus early post-transplantation, and progression rate of fibrosis in hepatitis C virus (HCV) positive patients.
Detailed description
This 24-month study consisted of a screening period, a baseline period (3 to 7 days post-transplantation) followed by a run-in period that ended on the day of randomization at 30 days (± 5 days) post-transplantation. Patients were screened for eligibility prior to liver transplantation. Patients who had undergone successful liver transplantation were initiated on a tacrolimus-based regimen that included corticosteroids and entered the baseline period (between 3 and 7 days post-transplantation). At 30 (± 5) days post-transplantation, patients who met additional randomization inclusion/exclusion criteria were randomized into the study.
Interventions
Everolimus was started within 24 hours of randomization at a dose of 1.0 mg twice a day (bid, 2 mg daily dose). The dose was adjusted to maintain everolimus trough blood levels between 3-8 ng/mL for the duration of the study.
After everolimus whole blood trough levels were confirmed to be in the target range of 3-8 ng/mL, tacrolimus tapering began, achieving a target tacrolimus whole blood trough level of 3-5 ng/mL by 3 weeks after randomization, a level which was maintained for the duration of the study.
After everolimus whole blood trough levels were confirmed to be in the target range of 3-8 ng/mL, tacrolimus tapering began, achieving a target tacrolimus whole blood trough level of 3-5 ng/mL by 3 weeks after randomization. Tacrolimus elimination was started beginning at Month 4. Tacrolimus was tapered after everolimus whole blood trough levels were within the target range of 6-10 ng/mL. Tacrolimus was completely eliminated by the end of Month 4.
Tacrolimus trough levels were targeted to be maintained at 8-12 ng/mL until Month 4. At Month 4, tacrolimus whole blood trough levels were decreased to a target trough level of 6-10 ng/mL for the remainder of the study.
Everolimus was started within 24 hours of randomization at a dose of 1.0 mg twice a day (bid, 2 mg daily dose). The dose was adjusted to maintain everolimus trough blood levels between 3-8 ng/mL until Month 4; beginning with Month 4, the dose was adjusted to maintain everolimus trough blood levels between 6-10 ng/mL.
DRUGCorticosteroids
For patients in all groups, corticosteroids were initiated at or prior to the time of transplantation according to local practice. Corticosteroids could be used for the duration of the study but could not be eliminated before Month 6.
Sponsors
Novartis Pharmaceuticals
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 70 Years
Healthy volunteers
No
Inclusion criteria
* Ability and willingness to provide written informed consent and adhere to study regimen. * Recipients who are 18-70 years of age of a primary liver transplant from a deceased donor. * Recipients who have been initiated on an immunosuppressive regimen that contains corticosteroids and tacrolimus, 3-7 days post-transplantation. * Confirmed recipient hepatitis C virus (HCV) status at Screening (either by antibody or by PCR (polymerase chain reaction). * Allograft is functioning at an acceptable level by the time of randomization as defined by protocol specific laboratory values. * Abbreviated Modification of Diet in Renal Disease estimated glomerular filtration rate (MDRD eGFR) ≥ 30 mL/min/1.73m2. Results obtained within 5 days prior to randomization are acceptable, however, no sooner than Day 25 post-transplantation. * Verification of at least 1 tacrolimus trough level of ≥ 8 ng/mL in the week prior to randomization. Investigators should make adjustments in tacrolimus dosing to continue to target trough levels above 8 ng/mL prior to randomization.
Exclusion criteria
* Patients who are recipients of multiple solid organ or islet cell tissue transplants, or have previously received an organ or tissue transplant. Patients who have a combined liver-kidney transplant. * Recipients of a liver from a living donor, or of a split liver. * History of malignancy of any organ system within the past 5 years whether or not there is evidence of local recurrence or metastases, other than non-metastatic basal or squamous cell carcinoma of the skin, or HCC (hepatocellular carcinoma) (see next criteria). * Hepatocellular carcinoma that does not fulfill Milan criteria (1 nodule ≤ 5 cm, 2-3 nodules all \< 3 cm) at the time of transplantation as per explant histology of the recipient liver. * Any use of antibody induction therapy. * Patients with a known hypersensitivity to the drugs used on study or their class, or to any of the excipients. * Patients who are recipients of ABO incompatible transplant grafts. * Recipients of organs from donors who test positive for Hepatitis B surface antigen or HIV are excluded. * Patients who have any surgical or medical condition, which in the opinion of the investigator, might significantly alter the absorption, distribution, metabolism and excretion of study drug. * Women of child-bearing potential (WOCBP). * Patients with any history of coagulopathy or medical condition requiring long-term anticoagulation which would preclude liver biopsy after transplantation. (Low dose aspirin treatment or interruption of chronic anticoagulant is allowed). Other protocol-defined inclusion/
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Incidence Rate of Composite Efficacy Failure From Randomization to Month 12 | Randomization to Month 12 | Composite efficacy failure was defined as treated biopsy proven acute rejection (tBPAR), graft loss, or death. A BPAR was defined as an acute rejection confirmed by biopsy with a Rejection Activity Index (RAI) score ≥ 3. tBPAR was defined as a BPAR which was treated with anti-rejection therapy. The RAI is used to score liver biopsies with acute rejection and is composed of 3 categories (portal inflammation, bile duct inflammation damage, venous endothelial inflammation) each scored on a scale of 0 (absent) to 3 (severe) by a trained pathologist. The total RAI score = the sum of the scores of the 3 categories and ranges from 0 to 9, with a higher score indicating greater rejection. The graft was presumed to be lost on the day the patient was newly listed for a liver graft, they received a graft re-transplant, or they died. The incidence rates of composite efficacy failure were estimated with a Kaplan-Meier product-limit formula. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Incidence Rate of Composite Efficacy Failure From Randomization to Month 24 | Randomization to Month 24 | Composite efficacy failure was defined as treated biopsy proven acute rejection (tBPAR), graft loss, or death. The incidence rates of composite efficacy failure were estimated with a Kaplan-Meier product-limit formula. |
| Incidence Rate of Treated Biopsy Proven Acute Rejection (tBPAR) at Months 12 and 24 | Randomization to Month 24 | tBPAR was defined as an acute rejection confirmed by biopsy with a Rejection Activity Index (RAI) score ≥ 3, which was treated with anti-rejection therapy. Liver biopsies were collected for all cases of suspected acute rejection preferably within 24 hours, at the latest within 48 hours, whenever clinically possible. The RAI is used to score liver biopsies with acute rejection and is composed of 3 categories (portal inflammation, bile duct inflammation damage, venous endothelial inflammation) each scored on a scale of 0 (absent) to 3 (severe) by a trained pathologist. The total RAI score = the sum of the scores of the 3 categories and ranges from 0 to 9, with a higher score indicating greater rejection. The graft was presumed to be lost on the day the patient was newly listed for a liver graft, they received a graft re-transplant, or they died. The incidence rates of tBPAR were estimated with a Kaplan-Meier product-limit formula. |
| Change in Renal Function From Randomization to Months 12 and 24 | Randomization to Month 24 | Change in renal function was assessed by the estimated Glomerular Filtration Rate (eGFR) using the abbreviated (4 variables) Modification of Diet in Renal Disease (MDRD-4) formula which was developed by the MDRD Study Group and has been validated in patients with chronic kidney disease. The MDRD-4 formula used for the eGFR calculation is: eGFR (mL/min/1.73m\^2) = 186.3\*(C\^-1.154)\*(A\^-0.203)\*G\*R, where C is the serum concentration of creatinine (mg/dL), A is age (years), G=0.742 when gender is female, otherwise G=1, R=1.21 when race is black, otherwise R=1. The changes in renal function were analyzed via analysis of covariance (ANCOVA) with treatment, pre-transplant hepatitis C virus status and randomization eGFR as covariates. Based on these ANCOVA analyses, the least-squares mean and standard errors of change were reported. |
Countries
Argentina, Australia, Belgium, Brazil, Canada, Colombia, Czechia, France, Germany, Hungary, Ireland, Israel, Italy, Netherlands, Russia, Spain, Sweden, United Kingdom, United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Everolimus + Reduced Tacrolimus Low dose tacrolimus (tacrolimus reduced) + everolimus + corticosteroids. | 245 |
| Tacrolimus Elimination Low-dose tacrolimus (until Month 4, then tacrolimus eliminated) + everolimus + corticosteroids. | 231 |
| Tacrolimus Control Arm Control dose tacrolimus + corticosteroids. | 243 |
| Total | 719 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 | FG002 |
|---|---|---|---|---|
| Overall Study | Administrative Problems | 11 | 17 | 13 |
| Overall Study | Death | 12 | 15 | 10 |
| Overall Study | Graft Loss | 5 | 3 | 2 |
| Overall Study | Lost to Follow-up | 2 | 4 | 2 |
| Overall Study | Missing | 0 | 1 | 1 |
| Overall Study | Subject Withdrew Consent | 13 | 17 | 11 |
Baseline characteristics
| Characteristic | Everolimus + Reduced Tacrolimus | Tacrolimus Elimination | Tacrolimus Control Arm | Total |
|---|---|---|---|---|
| Age Continuous | 53.6 years STANDARD_DEVIATION 9.2 | 53.2 years STANDARD_DEVIATION 10.8 | 54.5 years STANDARD_DEVIATION 8.7 | 53.8 years STANDARD_DEVIATION 9.6 |
| Sex: Female, Male Female | 65 Participants | 67 Participants | 64 Participants | 196 Participants |
| Sex: Female, Male Male | 180 Participants | 164 Participants | 179 Participants | 523 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk |
|---|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — | — / — |
| other Total, other adverse events | 218 / 245 | 194 / 229 | 205 / 242 |
| serious Total, serious adverse events | 138 / 245 | 152 / 229 | 131 / 242 |
Outcome results
Primary
Incidence Rate of Composite Efficacy Failure From Randomization to Month 12
Composite efficacy failure was defined as treated biopsy proven acute rejection (tBPAR), graft loss, or death. A BPAR was defined as an acute rejection confirmed by biopsy with a Rejection Activity Index (RAI) score ≥ 3. tBPAR was defined as a BPAR which was treated with anti-rejection therapy. The RAI is used to score liver biopsies with acute rejection and is composed of 3 categories (portal inflammation, bile duct inflammation damage, venous endothelial inflammation) each scored on a scale of 0 (absent) to 3 (severe) by a trained pathologist. The total RAI score = the sum of the scores of the 3 categories and ranges from 0 to 9, with a higher score indicating greater rejection. The graft was presumed to be lost on the day the patient was newly listed for a liver graft, they received a graft re-transplant, or they died. The incidence rates of composite efficacy failure were estimated with a Kaplan-Meier product-limit formula.
Time frame: Randomization to Month 12
Population: Intent-to-treat population: All randomized patients.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Everolimus + Reduced Tacrolimus | Incidence Rate of Composite Efficacy Failure From Randomization to Month 12 | 6.7 Percentage of participants |
| Tacrolimus Elimination | Incidence Rate of Composite Efficacy Failure From Randomization to Month 12 | 24.2 Percentage of participants |
| Tacrolimus Control Arm | Incidence Rate of Composite Efficacy Failure From Randomization to Month 12 | 9.7 Percentage of participants |
Secondary
Change in Renal Function From Randomization to Months 12 and 24
Change in renal function was assessed by the estimated Glomerular Filtration Rate (eGFR) using the abbreviated (4 variables) Modification of Diet in Renal Disease (MDRD-4) formula which was developed by the MDRD Study Group and has been validated in patients with chronic kidney disease. The MDRD-4 formula used for the eGFR calculation is: eGFR (mL/min/1.73m\^2) = 186.3\*(C\^-1.154)\*(A\^-0.203)\*G\*R, where C is the serum concentration of creatinine (mg/dL), A is age (years), G=0.742 when gender is female, otherwise G=1, R=1.21 when race is black, otherwise R=1. The changes in renal function were analyzed via analysis of covariance (ANCOVA) with treatment, pre-transplant hepatitis C virus status and randomization eGFR as covariates. Based on these ANCOVA analyses, the least-squares mean and standard errors of change were reported.
Time frame: Randomization to Month 24
Population: Intent-to-treat population: All randomized patients.
| Arm | Measure | Group | Value (LEAST_SQUARES_MEAN) | Dispersion |
|---|---|---|---|---|
| Everolimus + Reduced Tacrolimus | Change in Renal Function From Randomization to Months 12 and 24 | Month 12 (N=244, 231, 243) | -2.23 mL/min/1.73m^2 | Standard Error 1.54 |
| Everolimus + Reduced Tacrolimus | Change in Renal Function From Randomization to Months 12 and 24 | Month 24 (N=245, 231, 243) | -7.94 mL/min/1.73m^2 | Standard Error 1.53 |
| Tacrolimus Elimination | Change in Renal Function From Randomization to Months 12 and 24 | Month 12 (N=244, 231, 243) | -1.51 mL/min/1.73m^2 | Standard Error 1.58 |
| Tacrolimus Elimination | Change in Renal Function From Randomization to Months 12 and 24 | Month 24 (N=245, 231, 243) | -4.19 mL/min/1.73m^2 | Standard Error 1.58 |
| Tacrolimus Control Arm | Change in Renal Function From Randomization to Months 12 and 24 | Month 12 (N=244, 231, 243) | -10.73 mL/min/1.73m^2 | Standard Error 1.54 |
| Tacrolimus Control Arm | Change in Renal Function From Randomization to Months 12 and 24 | Month 24 (N=245, 231, 243) | -14.60 mL/min/1.73m^2 | Standard Error 1.54 |
Secondary
Incidence Rate of Composite Efficacy Failure From Randomization to Month 24
Composite efficacy failure was defined as treated biopsy proven acute rejection (tBPAR), graft loss, or death. The incidence rates of composite efficacy failure were estimated with a Kaplan-Meier product-limit formula.
Time frame: Randomization to Month 24
Population: Intent-to-treat population: All randomized patients.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Everolimus + Reduced Tacrolimus | Incidence Rate of Composite Efficacy Failure From Randomization to Month 24 | 10.3 Percentage |
| Tacrolimus Elimination | Incidence Rate of Composite Efficacy Failure From Randomization to Month 24 | 26.0 Percentage |
| Tacrolimus Control Arm | Incidence Rate of Composite Efficacy Failure From Randomization to Month 24 | 12.5 Percentage |
Secondary
Incidence Rate of Treated Biopsy Proven Acute Rejection (tBPAR) at Months 12 and 24
tBPAR was defined as an acute rejection confirmed by biopsy with a Rejection Activity Index (RAI) score ≥ 3, which was treated with anti-rejection therapy. Liver biopsies were collected for all cases of suspected acute rejection preferably within 24 hours, at the latest within 48 hours, whenever clinically possible. The RAI is used to score liver biopsies with acute rejection and is composed of 3 categories (portal inflammation, bile duct inflammation damage, venous endothelial inflammation) each scored on a scale of 0 (absent) to 3 (severe) by a trained pathologist. The total RAI score = the sum of the scores of the 3 categories and ranges from 0 to 9, with a higher score indicating greater rejection. The graft was presumed to be lost on the day the patient was newly listed for a liver graft, they received a graft re-transplant, or they died. The incidence rates of tBPAR were estimated with a Kaplan-Meier product-limit formula.
Time frame: Randomization to Month 24
Population: Intent-to-treat population: All randomized patients.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Everolimus + Reduced Tacrolimus | Incidence Rate of Treated Biopsy Proven Acute Rejection (tBPAR) at Months 12 and 24 | Month 12 | 3.0 Percentage |
| Everolimus + Reduced Tacrolimus | Incidence Rate of Treated Biopsy Proven Acute Rejection (tBPAR) at Months 12 and 24 | Month 24 | 4.8 Percentage |
| Tacrolimus Elimination | Incidence Rate of Treated Biopsy Proven Acute Rejection (tBPAR) at Months 12 and 24 | Month 12 | 18.8 Percentage |
| Tacrolimus Elimination | Incidence Rate of Treated Biopsy Proven Acute Rejection (tBPAR) at Months 12 and 24 | Month 24 | 19.9 Percentage |
| Tacrolimus Control Arm | Incidence Rate of Treated Biopsy Proven Acute Rejection (tBPAR) at Months 12 and 24 | Month 12 | 7.2 Percentage |
| Tacrolimus Control Arm | Incidence Rate of Treated Biopsy Proven Acute Rejection (tBPAR) at Months 12 and 24 | Month 24 | 7.7 Percentage |