Everolimus bAsed caLcineurin inhibiTor frEe immunosuppRession oNe Year AfTer lIver transplantatiON (ALTERNATION)

Randomized, prospective, multicenter, open-label, controlled trial in Liver allograft recipients beyond year one after transplantation (12-36 Months after liver transplantation) without graft dysfunction and with a surveillance biopsy without relevant subclinical graft injury.

The population of the trial will be adult LTR (≥18 and < 80 years at the study entry) beyond the first year after OLT, who are eligible for a svLBx. The aim of this study is to compare two regimens of a reduced IS in the first year after OLT. Therefore, patients with an increased rejection risk have to be excluded by relevant liver enzyme elevation (ALT, and ALP > 2 ULN) and by a svLBx showing relevant graft injury guided by the BANFFmini criteria. These thresholds have been safely used by several studies with a complete IS withdrawal and should be safe for the proposed study which rather aims for a moderate reduction of IS. Within our single center program for biopsy guided personalized immunosuppression an extension of this strict BANFFmini criteria was safe in patients with immunosuppression minimization but no complete withdrawal.

LTR with a putative intolerance of the increased IS after a rejection provoked by the study intervention (steroid boli or higher CNI doses) like older patients, pregnant woman or patients with advanced kidney failure (eGFR < 30 ml/min), ongoing infections or malignancies will also be excluded. We would not exclude per se LTR with autoimmune liver diseases as cause for OLT, because we did not observe any increased rejection risk in this patient population using a reduced IS with low dose CNI in our single center personalized IS program. Patients with an increased risk to be harmed by EVR, e.g. preexisting proteinuria, will be excluded as well. Screening of patients that are already on EVR/CNI combination therapy can be performed according to the judgement of participating centers. LTR on EVR/CNI because of reduced kidney function or because of recurrent viral infection, will not be harmed by the study, because both groups - intervention and SOC - will not lead to an increase in CNI dosage compared to the dosage before. Patients on EVR/CNI because of hepatocellular carcinoma: There is no prospective data showing an overall long-term survival benefit from a mTORI-based regimen and there is no prospective data showing a survival benefit between a mTORI containing regimen vs a low dose CNI regimen.

In contrast to previous studies on CNI-free mTORI-based IS, we will not focus exclusively on patients with a preexisting renal failure. Since we do not expect a relevantly increased rejection risk by the study intervention, the potential rejection risk has not to be balanced by a higher chance to benefit from renal protective IS as in previously performed trials. Therefore, it is ethically justifiable to include patients without significant renal impairment and thus to let them benefit from the possible benefit of the intervention.

The inclusion and exclusion criteria will select healthy LTR and more motivated patients that are willing to undergo a svLBx. However, the screening via a svLBx is essential considering the rate of BANFFmini in 30-40% of patients.

Patients in the intervention group will be switched to a mTORI-based immunosuppression (EVR 3-8ng/ml) with MMF (250-750 mg bid). CNI will be tapered stepwise in the 2 months lead-in phase.

Patients serving as control group need to fulfill the same inclusion criteria as the intervention group. Since they will also be eligible for minimization of IS guided by Banff criteria, after randomization IS will be provided based on a low dose CNI regime (Tac trough levels 2-4 ng/ml) with or without MMF (250 mg bid) as it is current standard of care. Patients, who have already been on low-dose CNI, will continue on their previous IS regime. According to recently published data showing reduced nephrotoxicity with a combined endpoint with new onset diabetes and new arterial hypertension with LCP-Tac Versus extended-released TAC, the preferred TAC in the study will be LCP-Tac. Only in case of intolerance, other tacrolimus preparations or CYS (trough level 50-80 ng/ml) should be used and discussion with the coordinating investigator may be advised.

In parallel for both study arms, a further minimization step to a low dose CNI therapy (control arm) or EVR low dose (trough level 3-6 ng/ml) both without MMF is advised after 14 months svLBx showing still no relevant graft injury.

Inclusion criteria

• Men**, women*, inter/diverse aged ≥ 18 or <80 years
• Signed written informed consent from subject
• Liver allograft recipients, either deceased or living donor liver transplant
• Liver transplantation more than 12 months ago and less than 36 months ago
• Recipients of single organ transplant only
• LTR on CNI-based maintenance IS
• Liver enzymes: ALT < 2x ULN and ALP< 2 ULN
• *Women without childbearing potential defined as follows:

• at least 6 weeks after surgical sterilization by bilateral tubal ligation or bilateral oophorectomy or
• hysterectomy or uterine agenesis or
• ≥ 50 years and in postmenopausal state > 1 year or
• < 50 years and in postmenopausal state > 1 year with serum FSH > 40 IU/l and serum estrogen < 30 ng/l or a negative estrogen test, both at screening or

*Women of childbearing potential:

• who are practicing sexual abstinence (periodic abstinence and withdrawal are not acceptable) or
• who have sexual relationships with female partners only and/or with sterile male partners or
• who are sexually active with fertile male partner, have two negative pregnancy tests with a sensitivity of at least 25 mIU/ml during screening (it is recommended that the second test be performed 8-10 days after the first test) and agree to use at least one highly *** from the time of screening until 8 weeks after completion of treatment (or even 90 days for males if MMF has been taken previously). Preferably, two complementary forms of contraception should be used simultaneously. Pregnancy tests should be repeated if clinically indicated (e.g. after a contraceptive failure has been reported).

Exclusion criteria

• Previous CNI-free IS
• Acute or chronic rejection within the 36 months prior to screening
• Prednisolone intake due to another autoimmune disease for more than 8 weeks
• eGFR <30ml/min and/or proteinuria >0.5g/l (to mitigate the risk of worsening renal failure should rejection occur and high level of CNI might be required and proteinuria as a contraindication for mTORI-based therapy)
• Need for chronic anti-coagulation that cannot be safely discontinued to perform a liver biopsy
• Inability to participate in frequent monitoring of liver function (every 8 weeks) and clinical visits during the trial duration (38 months)
• Malignancy or active infection including active, replicative viral hepatitis (chronic hepatitis does not belong to exclusion criteria)
• Recurrence of underlying liver disease
• Subjects who are pregnant or breastfeeding
• Hypersensitivity or intolerance to any of the components of the medications used
• Participation in another clinical trial (other investigational drugs or devices at the time of enrolment or within 30 days prior enrolment or within five half-lives of the Investigational Medicinal Product (IMP), whichever is longer)
• Any medical condition which could compromise participation in the study according to the investigator's assessment.
• Accommodation in an institution pursuant to a court or administrative order
• Histological exclusion criteria in the baseline screening biopsy:

• more than mild portal tract inflammation, presence of interface hepatitis, more than mild lobular inflammation
• presence of biliary inflammation, endothelialitis, portal microvasculitis, central perivenulitis
• advanced fibrosis (≥2 in any scale of LAF score)
• evidence of acute or chronic rejection (T cell-mediated or antibody-mediated, plasma-cell-rich, chronic ductopenic rejection)