De Novo Everolimus Versus Tacrolimus in Combination With Mofetil Mycophenolate and Low Dose Corticosteroids to Reduce Tacrolimus Induced Nephrotoxicity in Liver Transplantation: a Prospective, Multicentric, Randomised Study

Rennes University Hospital

Overview

Tacrolimus is a calcineurin inhibitor. This is the immunosuppression of reference for patients undergoing a first liver transplant. This treatment can prevent graft rejection, but can cause side effects including kidney failure (in 25% after the first year). Everolimus is an immunosuppressive that effectively prevents acute rejection in heart and kidney transplant recipients. It preserves renal function when it is started soon after the transplant, i.e. before a severe dysfunction is installed.

In the liver transplant, early interruption of calcineurin inhibitors with a quick relay everolimus monotherapy preserves renal function and is associated with a lower acute rejection rate. We wish to assess whether the introduction of a de novo immunosuppression everolimus under protection of basiliximab induction, mycophenolate mofetil and then low doses of corticosteroids, reduces the nephrotoxicity of immunosuppressive therapy in liver transplant patients, compared to a standard protocol with tacrolimus associated with mycophenolate mofetil and low dose corticosteroids.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

PREVENTION

Masking

NONE

Conditions

Liver Transplantation

Interventions

TacrolimusDRUG

Tacrolimus is administered at an initial dose of 0.040 mg / kg twice a day on Day 5. The doses are then adjusted to maintain trough levels : * between 6 and 10 ng / ml during the first 2 months, * between 5 and 8 ng / ml from the start of the end M3 and M6, * and between 4 and 6 ng / ml between the beginning and the end of M7 M12.

EverolimusDRUG

Everolimus is administered at an initial dose of 1.5 mg twice a day on Day 5. The doses are then adjusted to maintain trough levels: * between 6 and 10 ng / ml during the first 2 months, * between 5-8 ng / ml from the start of the end M3 and M6, * and between 4 and 6 ng / ml between the beginning and the end of M7 M12.

Mycophenolate mofetilDRUG

mycophenolate mofetil is administered similarly in the two groups at the dose of 1.5 g for the first two months and then 1 g twice a day. The doses may be adjusted according to the tolerance of the product.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Pre-transplantation Inclusion Criteria: * Adults (≥18 years), male or female, * Patients due to receive a first liver transplant with a full or reduced graft taken from a donor brain-dead beating heart or a related living donor, * Patients having given a free and informed written consent . Post-transplantation Inclusion criteria: Patients meeting the following criteria will be included: * Receiving basiliximab (Simulect) * Whose immunosuppression regimen from day 5 could immediately consist of either tacrolimus or everolimus, in combination with mycophenolate mofetil and low dose corticosteroids * With hepatic artery permeable to echo Doppler 4 days after transplant. Exclusion Criteria: * History of immunosuppressive therapy, * Known hypersensitivity to the treatments or macrolides, * HIV infection * Autoimmune hepatitis, * Primary sclerosing cholangitis, * Programming or realization of a combined transplant, * Pregnancy or lack of effective contraception, * Breastfeeding. * Incompatibility with the donor, * Thrombosis of the hepatic artery between D0 and D4, * Non-primary graft function leading to a re-registration on the waiting list.

Outcomes

Primary Outcomes

Worsening of renal function

The main objective of the study is to evaluate, in liver transplanted patients, the benefit in terms of prevention of renal failure, a regimen that includes a de novo introduction of everolimus instead of tacrolimus, in combination with mycophenolate mofetil and low doses of corticosteroids, to the extent that this benefit is not accompanied by an increased risk of graft loss or hepatic artery thrombosis. Insofar as the objective of the study is to assess a risk / benefit ratio, the study has two main criteria. Worsening renal function is validated before the prolonged decline (found on at least 3 assays carried out at least 3 months apart) over 30% of the creatinine clearance compared to the value at baseline . The date of the first evidence of this worsening of renal function is the date used to calculate the distribution of censored criterion.

Time frame: Between the initiation of treatment (Day 5) and the end (week 48) (censored criterion)

Occurrence of graft loss

Graft loss , whatever the cause, or thrombosis of the hepatic artery are recorded between baseline and the end of S48 (censored criterion).

Time frame: Between the baseline and the end of the treatment (week 48) (censored criterion

Secondary Outcomes

Plasma creatinine

Time frame: At the end of the treatment (week 48)

Glomerular filtration rate

Glomerular filtration rate calculated following Modification of Diet in Renal Disease (MDRD) formula

Time frame: At the end of the treatment (week 48)

Occurrence of mental trouble

Occurrence of an episode of confusion, agitation or delirium assessed by neurological examination

Time frame: Between the baseline and the end of the treatment (week 48) (censored criterion)

Data from ClinicalTrials.gov

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