Minimizing immunosuppression in liver transplant patients using everolimus

Expanding Liver Transplant Immunosuppression Minimization Via Everolimus (CTOT-43)

This study is testing if liver transplant patients can safely lower or stop taking tacrolimus by switching to everolimus to help protect their kidney function.

Quick facts

• Phase: Phase 2
• Study type: Interventional
• Enrollment: 340 (estimated)
• Ages: 18 Years and up
• Sex: All
• Sponsor: National Institute of Allergy and Infectious Diseases (NIAID) (NIH)
• Locations: 8 sites (Phoenix, Arizona and 7 other locations)
• Trial ID: NCT06280950 on ClinicalTrials.gov

What this trial studies

This clinical trial aims to evaluate the safety, efficacy, and tolerability of reducing and eventually withdrawing tacrolimus, an anti-rejection medication, in liver transplant recipients while using everolimus as a monotherapy to help preserve kidney function. A total of 270 participants will be randomized into two groups: one will undergo a stepwise reduction of tacrolimus and switch to everolimus, while the other will maintain a reduced dose of tacrolimus alongside everolimus. The study will last 18-20 months and will assess the outcomes of these treatment strategies in a multicenter setting.

Who should consider this trial

Good fit: Ideal candidates include adult recipients of a first liver transplant who are currently on tacrolimus therapy and have adequate kidney function.

Not a fit: Patients who are unable to tolerate everolimus or have unresolved infections may not benefit from this study.

Why it matters

Potential benefit: If successful, this approach could lead to improved kidney function and reduced side effects for liver transplant recipients.

How similar studies have performed: Other studies have explored similar immunosuppression minimization strategies, showing promising results, but this specific approach with everolimus is relatively novel.

Eligibility criteria

Inclusion Criteria:

1. Subject and/or legal guardian must be able to understand and provide informed consent
2. Adult (age greater than or equal to 18 years of age at time of informed consent) recipient of first liver transplant alone (de novo)
3. Estimated glomerular filtration rate \>=30 ml/min/1.73m\^2 at enrollment using the CKD-EPI 2021 equation
4. Treatment with tacrolimus therapy, with or without mycophenolic acid derivatives and/or corticosteroids
5. Female subjects of childbearing potential with negative pregnancy test upon study entry
6. All subjects of reproductive potential agreeing to use contraception for the duration of the study
7. Previous vaccination or documented immunity to varicella, measles, hepatitis B, pneumococcus, influenza, zoster (if \>=19 years old), and 2019-nCoV (COVID-19) as outlined in the DAIT Vaccination Guideline

Exclusion Criteria:

1. Inability or unwillingness of a participant to give written informed consent or comply with study protocol
2. Active unresolved systemic viral, bacterial, fungal, or parasitic infection requiring oral or intravenous anti-infective therapy
3. History of autoimmune liver disease including autoimmune hepatitis, primary sclerosing cholangitis, and/or primary biliary cirrhosis, or other contraindications to drug withdrawal
4. History of non-hepatic autoimmune disease requiring current or future systemic immunosuppressive therapy other than per study protocol
5. History post-transplant of Hepatic Artery Thrombosis or Portal Vein Thrombosis.
6. History of recurrent cirrhosis after liver transplantation.
7. Chronic use of systemic glucocorticoids, biological immunomodulatory therapy, or other immunosuppressive agents other than per study protocol
8. History of hepatitis B or C virus infection with detectable viral PCR at enrollment
9. History of prior organ transplantation (liver or other type)
10. History of \>= 2 biopsy-proven acute cellular rejection episodes of any severity, \>=1 moderate to severe rejection episode (histologically defined or requiring lymphodepletion therapy), or \>= 1 antibody- mediated rejection episode
11. Active treatment with any mTOR-inhibitor agent (everolimus, sirolimus)
12. Contraindication to treatment with everolimus (open wound or wound infection; urine protein: creatinine ratio \> 0.5; significant pancytopenia (any of the following: WBC \<1.5 K/uL or ANC \<1000 cells/uL or actively being treated with GCSF; Hb \<8.0; platelet count \<50K); serum triglycerides \> 1000 mg/dL; other per PI)
13. Abnormal liver function tests on study entry: Total Bilirubin (TB)\>1.5 mg/dL and Direct Bilirubin (DB) \>1.0 mg/dL, Alkaline Phosphatase (AP) \>200 U/L, and Alanine Aminotransaminase (ALT)\>60 U/L
14. Pregnant on enrollment or plan to become pregnant during the study period
15. Participation in another clinical trial that would interfere with this study's procedures and intervention:

    1. Use of investigational biologic or drug (within 8 weeks of study enrollment)
    2. Additional blood collection that would exceed research blood draw limits
    3. Any other procedure or intervention, in the investigator's opinion would interfere with this study
16. Received live attenuated vaccine(s) within 2 months of enrollment
17. Current, diagnosed, mental illness or current, diagnosed, or self-reported drug or alcohol abuse that, in the opinion of the investigator, would interfere with the participant's ability to comply with study requirements or that may impact the quality or interpretation of the data obtained from the study
18. Past or current medical problems or findings from physical examination or laboratory testing that are not listed above, which, in the opinion of the investigator, may pose additional risks from participation in the study, may interfere with the participant's ability to comply with study requirements or that may impact the quality or interpretation of the data obtained from the study.

Where this trial is running

Phoenix, Arizona and 7 other locations

• Mayo Clinic Hospital Arizona (Site #: 71144) — Phoenix, Arizona, United States (Recruiting)
• University of California, San Francisco (Site #: 71108) — San Francisco, California, United States (Recruiting)
• Northwestern University (Site #: 71110) — Chicago, Illinois, United States (Recruiting)
• Icahn School of Medicine at Mount Sinai (Site #: 71115) — New York, New York, United States (Recruiting)
• Duke University Medical Center (Site #: 71139) — Durham, North Carolina, United States (Recruiting)
• University of Pennsylvania (Site #: 71111) — Philadelphia, Pennsylvania, United States (Recruiting)
• University of Pittsburgh Medical Center (Site #: 71170) — Pittsburgh, Pennsylvania, United States (Recruiting)
• Baylor Medical Center (Site #: 71153) — Dallas, Texas, United States (Recruiting)

Study contacts

• Principal investigator: Justin Boike, MD — Northwestern University Feinberg School of Medicine: Transplantation
• Study coordinator: Tracia Debnam, MS

Conditions Liver Transplant; Liver; Transplant; Everolimus