Efficacy and Safety of Everolimus and Mycophenolic Acid With Early Tacrolimus Withdrawal After Liver Transplantation: A Multicenter Randomized Trial

• Published in: American journal of transplantation Vol. 17; no. 7; pp. 1843 - 1852
• Main Authors: Saliba, F., Duvoux, C., Gugenheim, J., Kamar, N., Dharancy, S., Salamé, E., Neau‐Cransac, M., Durand, F., Houssel‐Debry, P., Vanlemmens, C., Pageaux, G., Hardwigsen, J., Eyraud, D., Calmus, Y., Di Giambattista, F., Dumortier, J., Conti, F.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Limited 01.07.2017; Elsevier
• Subjects: Biopsy; Calcineurin; calcineurin inhibitor (CNI); clinical research/practice; Epidermal growth factor receptors; Everolimus - pharmacology; Evidence-based medicine; Female; Follow-Up Studies; glomerular filtration rate (GFR); Graft rejection; Graft Rejection - diagnosis; Graft Rejection - drug therapy; Graft Rejection - etiology; Graft Survival - drug effects; Human health and pathology; Humans; Hépatology and Gastroenterology; Immunology; immunosuppressant; Immunosuppression; immunosuppression/immune modulation; Immunosuppressive Agents - pharmacology; Immunotherapy; Induction therapy; Inhibitor drugs; Kidneys; Life Sciences; Liver; Liver transplantation; Liver Transplantation - adverse effects; liver transplantation/hepatology; Liver transplants; Male; mechanistic target of rapamycin (mTOR); Middle Aged; Monoclonal antibodies; Mycophenolic acid; Mycophenolic Acid - pharmacology; Postoperative Complications; Prognosis; Prospective Studies; Risk Factors; Sodium; Steroid hormones; Tacrolimus; Tacrolimus - pharmacology; Transplantation; Transplants & implants; mechanistic target of rapamycin (mTOR); immunosuppression/immune modulation; clinical research/practice; glomerular filtration rate (GFR); immunosuppressant; calcineurin inhibitor (CNI); liver transplantation/hepatology
• DOI: 10.1111/ajt.14212
• ISSN: 1600-6135

SIMCER was a 6‐mo, multicenter, open‐label trial. Selected de novo liver transplant recipients were randomized (week 4) to everolimus with low‐exposure tacrolimus discontinued by month 4 (n = 93) or to tacrolimus‐based therapy (n = 95), both with basiliximab induction and enteric‐coated mycophenolate sodium with or without steroids. The primary end point, change in estimated GFR (eGFR; MDRD formula) from randomization to week 24 after transplant, was superior with everolimus (mean eGFR change +1.1 vs. −13.3 mL/min per 1.73 m2 for everolimus vs. tacrolimus, respectively; difference 14.3 [95% confidence interval 7.3–21.3]; p < 0.001). Mean eGFR at week 24 was 95.8 versus 76.0 mL/min per 1.73 m2 for everolimus versus tacrolimus (p < 0.001). Treatment failure (treated biopsy‐proven acute rejection [BPAR; rejection activity index score >3], graft loss, or death) from randomization to week 24 was similar (everolimus 10.0%, tacrolimus 4.3%; p = 0.134). BPAR was more frequent between randomization and month 6 with everolimus (10.0% vs. 2.2%; p = 0.026); the rate of treated BPAR was 8.9% versus 2.2% (p = 0.055). Sixteen everolimus‐treated patients (17.8%) and three tacrolimus‐treated patients (3.2%) discontinued the study drug because of adverse events. In conclusion, early introduction of everolimus at an adequate exposure level with gradual calcineurin inhibitor (CNI) withdrawal after liver transplantation, supported by induction therapy and mycophenolic acid, is associated with a significant renal benefit versus CNI‐based immunosuppression but more frequent BPAR. This multicenter, open‐label trial of de novo liver transplant recipients randomized at week 4 to everolimus with low‐exposure tacrolimus discontinued by month 4, or to standard tacrolimus‐based therapy with both basiliximab induction and enteric‐coated mycophenolate sodium ± steroids, shows a significant renal benefit for the everolimus‐treated group versus the control arm but more frequent mild or moderate biopsy‐proven acute rejection.