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

28 de julio de 2026 actualizado por: Hannover Medical School

Everolimus bAsed caLcineurin inhibiTor frEe immunosuppRession oNe Year AfTer lIver transplantatiON (ALTERNATION) - a Randomized, Prospective, Multicenter, Open-label, Controlled Phase III Trial

The overall aim of this study is nephroprotection based on a calcineurin inhibitor (CNI)-free therapy beyond year one after orthotopic liver transplantation (OLT) in highly pre-selected patients with low rejection risk.

Descripción general del estudio

Estado

Aún no reclutando

Condiciones

Intervención / Tratamiento

Descripción detallada

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.

Tipo de estudio

Intervencionista

Inscripción (Estimado)

150

Fase

  • Fase 3

Contactos y Ubicaciones

Esta sección proporciona los datos de contacto de quienes realizan el estudio e información sobre dónde se lleva a cabo este estudio.

Estudio Contacto

Copia de seguridad de contactos de estudio

Ubicaciones de estudio

    • Baden-Wurttemberg
      • Heidelberg, Baden-Wurttemberg, Alemania, 69120
        • University Hospital Heidelberg; Department of Internal Medicine IV
      • Tübingen, Baden-Wurttemberg, Alemania, 72076
        • University Hospital Tübingen, Department of Internal Medicine I
    • Bavaria
      • Regensburg, Bavaria, Alemania, 93053
        • University Hospital Regensburg, Department of Surgery
      • Würzburg, Bavaria, Alemania, 97080
        • University Hospital Würzburg, Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery
    • Free and Hanseatic City of Hamburg
      • Hamburg, Free and Hanseatic City of Hamburg, Alemania, 20246
        • University Medical Center Hamburg, I. Department of Medicine, Department of Hepatobiliary and Transplantation Surgery
    • Lower Saxony
      • Hanover, Lower Saxony, Alemania, 30625
        • Medical School Hannover, Department of Gastroenterology, Hepatology, Endocrinology and Infectious Diseases
    • Mecklenburg-Vorpommern
      • Rostock, Mecklenburg-Vorpommern, Alemania, 18057
        • University Medical Center Rostock, Interdisciplinary Transplant Center, Department of General, Visceral, Thoracic, Vascular, and Transplant Surgery
    • North Rhine-Westphalia
      • Aachen, North Rhine-Westphalia, Alemania, 52074
        • RWTH Aachen University Hospital, Clinic for Gastroenterology, Metabolic Disorders, and Internal Intensive Medicine (Medical Clinic III)
      • Bonn, North Rhine-Westphalia, Alemania, 53105
        • University Hospital Bonn, Department of General, Visceral, Transplant, and Vascular Surgery
      • Essen, North Rhine-Westphalia, Alemania, 45147
        • University Hospital Essen, Department of Gastroenterology, Hepatology, and Transplant Medicine
      • Münster, North Rhine-Westphalia, Alemania, 48149
        • University Hospital Münster, Department of Internal Medicine B Gastroenterology, Hepatology, Endocrinology, Clinical Infectious Diseases
    • Rhineland-Palatinate
      • Mainz, Rhineland-Palatinate, Alemania, 55131
        • University Medical Center of Johannes Gutenberg University Mainz, Department of Internal Medicine I
    • Saxony-Anhalt
      • Magdeburg, Saxony-Anhalt, Alemania, 39120
        • Otto von Guericke University Magdeburg, Department of Visceral, Vascular, and Transplant Medicine
    • Schleswig-Holstein
      • Kiel, Schleswig-Holstein, Alemania, 24105
        • Schleswig-Holstein University Hospital (UKSH), Department of General, Visceral, Thoracic, Transplant, and Pediatric Surgery, Campus Kiel
    • State of Berlin
      • Berlin, State of Berlin, Alemania, 13353
        • Charité - University Hospital Berlin; Department of Surgery
    • Thuringia
      • Jena, Thuringia, Alemania, 07747
        • University Hospital Jena, Department of General, Visceral, and Vascular Surgery

Criterios de participación

Los investigadores buscan personas que se ajusten a una determinada descripción, denominada criterio de elegibilidad. Algunos ejemplos de estos criterios son el estado de salud general de una persona o tratamientos previos.

Criterio de elegibilidad

Edades elegibles para estudiar

  • Adulto
  • Adulto Mayor

Acepta Voluntarios Saludables

No

Descripción

Inclusion Criteria:

  1. Men**, women*, inter/diverse aged ≥ 18 or <80 years
  2. Signed written informed consent from subject
  3. Liver allograft recipients, either deceased or living donor liver transplant
  4. Liver transplantation more than 12 months ago and less than 36 months ago
  5. Recipients of single organ transplant only
  6. LTR on CNI-based maintenance IS
  7. Liver enzymes: ALT < 2x ULN and ALP< 2 ULN
  8. *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:

  1. Previous CNI-free IS
  2. Acute or chronic rejection within the 36 months prior to screening
  3. Prednisolone intake due to another autoimmune disease for more than 8 weeks
  4. 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)
  5. Need for chronic anti-coagulation that cannot be safely discontinued to perform a liver biopsy
  6. Inability to participate in frequent monitoring of liver function (every 8 weeks) and clinical visits during the trial duration (38 months)
  7. Malignancy or active infection including active, replicative viral hepatitis (chronic hepatitis does not belong to exclusion criteria)
  8. Recurrence of underlying liver disease
  9. Subjects who are pregnant or breastfeeding
  10. Hypersensitivity or intolerance to any of the components of the medications used
  11. 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)
  12. Any medical condition which could compromise participation in the study according to the investigator's assessment.
  13. Accommodation in an institution pursuant to a court or administrative order
  14. Histological exclusion criteria in the baseline screening biopsy:

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

Plan de estudios

Esta sección proporciona detalles del plan de estudio, incluido cómo está diseñado el estudio y qué mide el estudio.

¿Cómo está diseñado el estudio?

Detalles de diseño

  • Propósito principal: Tratamiento
  • Asignación: Aleatorizado
  • Modelo Intervencionista: Asignación paralela
  • Enmascaramiento: Ninguno (etiqueta abierta)

Armas e Intervenciones

Grupo de participantes/brazo
Intervención / Tratamiento
Experimental: mTORI-based CNI-free IS
CNI-free IS with EVR (trough level 3-8 ng/ml) in combination with MMF (250-750 mg bid) with a second minimization step to EVR monotherapy depending on the 14 months (2 months lead in, 12 months full intervention) surveillance biopsy (svLbx)
Patients in the intervention group will be switched to CNI-free mTORI-based immunosuppression (EVR 3-8ng/ml) with MMF (250-750 mg bid)
Otros nombres:
  • mTORI
Comparador activo: Low dose CNI SOC
Standard of care meaning IS with CNI (TAC trough level 2-4 ng/ml or CYS trough level 50-80 ng/ml) with or without low dose MMF (250 mg bid) with a second minimization step to CNI monotherapy (if not already performed) depending on the 14 months (2 months lead in, 12 months full intervention) svLbx
Patients in the comparator group will be switched to a low dose CNI therapy (TAC trough level 2-4 ng/ml; CYS trough level 50-80 ng/ml) with or without low dose MMF 250 mg bid)
Otros nombres:
  • low dose CNI SOC

¿Qué mide el estudio?

Medidas de resultado primarias

Medida de resultado
Medida Descripción
Periodo de tiempo
Change from baseline to 14 months in the eGFR between CNI-free and SOC group
Periodo de tiempo: 14 months

The primary endpoint is change from baseline (CFB) to 14 months in the eGFR (ml/min) between the CNI-free and SOC group, where treatment effect is calculated by CFB-CNI-free minus CFB-SOC.

The primary analysis will be performed in the Intention to Treat (ITT) population, i.e. all study subjects will be analyzed as randomized.

The eGFR will be calculated using the new CKD-EPI Creatinine equation according to the national kidney foundation, 2021

14 months

Medidas de resultado secundarias

Medida de resultado
Medida Descripción
Periodo de tiempo
Acute liver graft rejection or liver graft loss until month 14
Periodo de tiempo: 14 months
Biopsy proven acute rejection (BPAR) (yes/no) is defined as liver enzyme elevation above 2x upper limit of normal (ULN) and histological criteria according to the most recent BANFF consensus
14 months
Change from baseline to 38 months in the eGFR
Periodo de tiempo: 38 months
Change in estimated glomerular filtration rate (eGFR (ml/min)) from baseline to end of follow-up (38 months)
38 months
Acute liver graft rejection or liver graft loss until month 38
Periodo de tiempo: 38 months
Biopsy proven acute rejection (BPAR) (yes/no) is defined as liver enzyme elevation above 2xULN and histological criteria according to the most recent BANFF consensus
38 months
Progression of chronic kidney disease
Periodo de tiempo: 38 months
-Progression of chronic kidney disease to stage 4, 5 or requirement for renal replacement therapy (yes/no)
38 months
Liver-related mortality
Periodo de tiempo: 38 months
-Incidence of liver-related mortality (yes/no)
38 months
-Progression of subclinical graft injury
Periodo de tiempo: 14 months
Progression of subclinical graft injury (fibrosis) at rebiopsy at month 14, where progression in the svLBx is defined as reaching histological exclusion criteria from baseline biopsy (≥ 2 points)
14 months
-Progression of subclinical graft injury
Periodo de tiempo: 38 months
Progression of subclinical graft injury (fibrosis) at rebiopsy at end of follow-up, where progression in the svLBx is defined as reaching histological exclusion criteria from baseline biopsy (≥ 2 points)
38 months
-Progression of subclinical inflammation
Periodo de tiempo: 14 months
-Progression of subclinical inflammation at rebiopsy at month 14 (yes/no) where inflammation in the svLBx is defined as reaching exclusion criteria from baseline biopsy (≥ 2 points in any subscore)
14 months
-Progression of subclinical inflammation
Periodo de tiempo: 38 months
-Progression of subclinical inflammation at rebiopsy at end of follow-up (yes/no) where inflammation in the svLBx is defined as reaching exclusion criteria from baseline biopsy (≥ 2 points in any subscore)
38 months
-Change in Quality of life measured with PROMIS
Periodo de tiempo: 14 months
Quality of life measured as change from baseline to months 14
14 months
-Change in Quality of life measured with SF-36
Periodo de tiempo: 14 months
Quality of life measured as change from baseline to months 14
14 months
-Change in Quality of life measured with PROMIS
Periodo de tiempo: 38 months
Quality of life measured as change from baseline to end of follow-up
38 months
-Change in Quality of life measured with SF-36
Periodo de tiempo: 38 months
Quality of life measured as change from baseline to end of follow-up
38 months
Donor Specific Antibodies
Periodo de tiempo: 38 months
-De novo development of donor specific Human Leukocyte Antigen (HLA) antibodies (yes/no)
38 months
Liver Stiffness
Periodo de tiempo: 38 months
-Increase in liver stiffness above 8,4 kilopascal (kPa) (yes/no)
38 months
Malignancy
Periodo de tiempo: 38 months
-Incidence of malignancy (yes/no)
38 months
Infections
Periodo de tiempo: 38 months
-Occurrence of infections requiring medical intervention or hospitalization (yes/no)
38 months
Comorbidities
Periodo de tiempo: 38 months
-New onset of comorbidities including hypertension (yes/no), dyslipoproteinemia (yes/no) and diabetes mellitus (yes/no)
38 months

Otras medidas de resultado

Medida de resultado
Medida Descripción
Periodo de tiempo
Rate of patients with elevated alanine aminotransferase (ALT)
Periodo de tiempo: 38 months
Elevation of Alanine aminotransferase (ALT) > 2x upper limit of normal (yes/no)
38 months
Rate of patients with elevated aspartate aminotransferase (AST)
Periodo de tiempo: 38 months
Elevation of aspartate aminotransferase (AST) > 2x upper limit of normal (yes/no)
38 months
Rate of patients with elevated alkaline phenyl phosphatase (ALP)
Periodo de tiempo: 38 months
Elevation of alkaline phenyl phosphatase (ALP) > 2x upper limit of normal (yes/no)
38 months
Rate of patients with elevated gamma-glutamyltransferase (GGT)
Periodo de tiempo: 38 months
Elevation of gamma-glutamyltransferase (GGT) > 2x upper limit of normal (yes/no)
38 months
Rate of patients with elevated international normalized ratio (INR)
Periodo de tiempo: 38 months
Elevation of international normalized ratio (INR) > 2x upper limit of normal (yes/no)
38 months
Adverse Events of Special Interest (AESI)
Periodo de tiempo: 38 months

The following events should be reported as AESI:

Allograft dysfunction; Steroid-resistant rejection, defined as rejection requiring, at the discretion of the local principal investigators, an additional course of high-dose corticosteroids or treatment with antithymocyte globulin/thymoglobulin or a comparable lymphocyte-depleting therapy; Chronic rejection as defined by Banff Foundation; Increase ≥2 points in any Liver Allograft Fibrosis (LAF) component in any follow up liver biopsy in central pathology report; Reaching the exclusion criteria in the central pathology report in any follow up liver biopsy

38 months

Colaboradores e Investigadores

Aquí es donde encontrará personas y organizaciones involucradas en este estudio.

Patrocinador

Colaboradores

Investigadores

  • Investigador principal: Richard Taubert, Professor, Medical School Hannover

Fechas de registro del estudio

Estas fechas rastrean el progreso del registro del estudio y los envíos de resultados resumidos a ClinicalTrials.gov. Los registros del estudio y los resultados informados son revisados ​​por la Biblioteca Nacional de Medicina (NLM) para asegurarse de que cumplan con los estándares de control de calidad específicos antes de publicarlos en el sitio web público.

Fechas importantes del estudio

Inicio del estudio (Estimado)

30 de junio de 2026

Finalización primaria (Estimado)

30 de junio de 2029

Finalización del estudio (Estimado)

30 de junio de 2031

Fechas de registro del estudio

Enviado por primera vez

15 de julio de 2026

Primero enviado que cumplió con los criterios de control de calidad

28 de julio de 2026

Publicado por primera vez (Actual)

31 de julio de 2026

Actualizaciones de registros de estudio

Última actualización publicada (Actual)

31 de julio de 2026

Última actualización enviada que cumplió con los criterios de control de calidad

28 de julio de 2026

Última verificación

1 de julio de 2026

Más información

Términos relacionados con este estudio

Información sobre medicamentos y dispositivos, documentos del estudio

Estudia un producto farmacéutico regulado por la FDA de EE. UU.

No

Estudia un producto de dispositivo regulado por la FDA de EE. UU.

No

Esta información se obtuvo directamente del sitio web clinicaltrials.gov sin cambios. Si tiene alguna solicitud para cambiar, eliminar o actualizar los detalles de su estudio, comuníquese con register@clinicaltrials.gov. Tan pronto como se implemente un cambio en clinicaltrials.gov, también se actualizará automáticamente en nuestro sitio web. .