H.J. Metselaar

Everolimus With Reduced Tacrolimus Improves Renal Function in De Novo Liver Transplant Recipients: A Randomized Controlled Trial

In a prospective, multicenter, open‐label study, de novo liver transplant patients were randomized at day 30±5 to (i) everolimus initiation with tacrolimus elimination (TAC Elimination) (ii) everolimus initiation with reduced‐exposure tacrolimus (EVR+Reduced TAC) or (iii) standard‐exposure tacrolimus (TAC Control). Randomization to TAC Elimination was terminated prematurely due to a higher rate of treated biopsy‐proven acute rejection (tBPAR). EVR+Reduced TAC was noninferior to TAC Control for the primary efficacy endpoint (tBPAR, graft loss or death at 12 months posttransplantation): 6.7% versus 9.7% (−3.0%; 95% CI −8.7, 2.6%; p<0.001 for noninferiority [12% margin]). tBPAR occurred in 2.9% of EVR+Reduced TAC patients versus 7.0% of TAC Controls (p = 0.035). The change in adjusted estimated GFR from randomization to month 12 was superior with EVR+Reduced TAC versus TAC Control (difference 8.50 mL/min/1.73 m2, 97.5% CI 3.74, 13.27 mL/min/1.73 m2, p<0.001 for superiority). Drug discontinuation for adverse events occurred in 25.7% of EVR+Reduced TAC and 14.1% of TAC Controls (relative risk 1.82, 95% CI 1.25, 2.66). Relative risk of serious infections between the EVR+Reduced TAC group versus TAC Controls was 1.76 (95% CI 1.03, 3.00). Everolimus facilitates early tacrolimus minimization with comparable efficacy and superior renal function, compared to a standard tacrolimus exposure regimen 12 months after liver transplantation.

Renal Function at Two Years in Liver Transplant Patients Receiving Everolimus: Results of a Randomized, Multicenter Study

In a 24‐month prospective, randomized, multicenter, open‐label study, de novo liver transplant patients were randomized at 30 days to everolimus (EVR)u2009+u2009Reduced tacrolimus (TAC; nu2009=u2009245), TAC Control (nu2009=u2009243) or TAC Elimination (nu2009=u2009231). Randomization to TAC Elimination was stopped prematurely due to a significantly higher rate of treated biopsy‐proven acute rejection (tBPAR). The incidence of the primary efficacy endpoint, composite efficacy failure rate of tBPAR, graft loss or death postrandomization was similar with EVRu2009+u2009Reduced TAC (10.3%) or TAC Control (12.5%) at month 24 (difference −2.2%, 97.5% confidence interval [CI] −8.8%, 4.4%). BPAR was less frequent in the EVRu2009+u2009Reduced TAC group (6.1% vs. 13.3% in TAC Control, pu2009=u20090.010). Adjusted change in estimated glomerular filtration rate (eGFR) from randomization to month 24 was superior with EVRu2009+u2009Reduced TAC versus TAC Control: difference 6.7u2009mL/min/1.73u2009m2 (97.5% CI 1.9, 11.4u2009mL/min/1.73u2009m2, pu2009=u20090.002). Among patients who remained on treatment, mean (SD) eGFR at month 24 was 77.6 (26.5)u2009mL/min/1.73u2009m2 in the EVRu2009+u2009Reduced TAC group and 66.1 (19.3)u2009mL/min/1.73u2009m2 in the TAC Control group (pu2009<u20090.001). Study medication was discontinued due to adverse events in 28.6% of EVRu2009+u2009Reduced TAC and 18.2% of TAC Control patients. Early introduction of everolimus with reduced‐exposure tacrolimus at 1 month after liver transplantation provided a significant and clinically relevant benefit for renal function at 2 years posttransplant.

The Importance of Portal Venous Blood Flow in Ischemic‐Type Biliary Lesions after Liver Transplantation

Ischemic‐type biliary lesions (ITBL) are the most frequent cause of nonanastomotic biliary strictures after liver transplantation. This complication develops in up to 25% of patients, with a 50% retransplantation rate in affected patients. Traditionally, ischemia‐reperfusion injury to the biliary system is considered to be the major risk factor for ITBL. Several other risk factors for ITBL have been identified, including the use of liver grafts donated after cardiac death, prolonged cold and warm ischemic times and use of University of Wisconsin preservation solution. In recent years however, impaired microcirculation of the peribiliary plexus (PBP) has been implicated as a possible risk factor. It is widely accepted that the PBP is exclusively provided by blood from the hepatic artery, and therefore, the role of the portal venous blood supply has not been considered as a possible cause for the development of ITBL. In this short report, we present three patients with segmental portal vein thrombosis and subsequent development of ITBL in the affected segments in the presence of normal arterial blood flow. This suggests that portal blood flow may have an important contribution to the biliary microcirculation and that a compromised portal venous blood supply can predispose to the development of ITBL.

REFINE: A Randomized Trial Comparing Cyclosporine A and Tacrolimus on Fibrosis After Liver Transplantation for Hepatitis C

REFINE was a 12‐month, prospective, open‐label study in 356 patients receiving de novo liver transplantation for hepatitis C virus (HCV) cirrhosis, randomized to cyclosporine A (CsA) or tacrolimus with (i) no steroids, IL‐2 receptor antibody induction and mycophenolic acid, or (ii) slow steroid tapering. The primary analysis population based on availability of liver biopsies comprised 165 patients (88 CsA, 77 tacrolimus). There was no difference in the primary endpoint, fibrosis stage ≥2 at 12 months, which occurred in 63/88 CsA‐treated patients (71.6%) and 52/77 tacrolimus‐treated patients (67.5%) (odds ratio [OR] 1.11; 95% CI 0.56, 2.21; pu2009=u20090.759). Similarly, no significant between‐group difference occurred at month 24 (OR 1.15; 95% CI 0.47, 2.80; pu2009=u20090.767). Among steroid‐free patients, fibrosis score ≥2 was significantly less frequent with CsA versus tacrolimus at month 12 (7/37 [18.9%] vs. 16/38 [42.1%]; pu2009=u20090.029). HCV viral load was similar in both the tacrolimus‐ and CsA‐treated cohorts. Mean blood glucose was significantly higher with tacrolimus from day 15 onward. Biopsy‐proven acute rejection, graft loss and death were similar. These results showed no differences in posttransplant HCV‐induced liver fibrosis between patients treated with CsA or tacrolimus in steroid‐containing regimens, whereas CsA in steroid‐free protocols was associated with reduced severity of fibrosis progression at 1 year posttransplant.

CMV Primary Infection Is Associated With Donor-Specific T Cell Hyporesponsiveness and Fewer Late Acute Rejections After Liver Transplantation

Viral infections, including cytomegalovirus (CMV), abrogate transplantation tolerance in animal models. Whether this also occurs in humans remains elusive. We investigated how CMV affects T cells and rejection episodes after liver transplantation (LT). Phenotype and alloreactivity of peripheral and allograft‐infiltrating T cells from LT patients with different CMV status were analyzed by flow cytometry. The association of CMV status with early and late acute rejection was retrospectively analyzed in a cohort of 639 LT patients. CMV‐positivity was associated with expansion of peripheral effector memory T cell subsets after LT. Patients with CMV primary infection showed donor‐specific CD8+ T cell hyporesponsiveness. While terminally differentiated effector memory cells comprised the majority of peripheral donor‐specific CD8+ T cells in CMV primary infection patients, they were rarely present in liver allografts. Retrospective analysis showed that R−D+ serostatus was an independent protective factor for late acute rejection by multivariate Cox regression analysis (hazard ratio [HR]u2009=u20090.18, 95% CIu2009=u20090.04–0.86, pu2009=u20090.015). Additionally, CMV primary infection patients showed the highest Vδ1/Vδ2 γδ T cell ratio, which has been shown to be associated with operational tolerance after LT. In conclusion, our data suggest that CMV primary infection may promote tolerance to liver allografts, and CMV status should be considered when tapering or withdrawing immunosuppression.

Chronic norovirus infection among solid organ recipients in a tertiary care hospital, the Netherlands, 2006-2014.

OBJECTIVESnImmunocompromised patients can suffer prolonged norovirus symptoms and virus shedding for many years. Little is known about the prevalence of chronic norovirus infection among solid organ transplant (SOT) recipients. In this study, 2182 SOT recipients were retrospectively tested for chronic norovirus infection.nnnMETHODSnThe first and last norovirus positive faecal samples of SOT recipients were sequenced to distinguish between persisting infection and re-infection. Patient charts were reviewed to obtain data on health status and treatments.nnnRESULTSnIn all, 101 of 2182 (4.6%) recipients were norovirus infected and 23 (22.8%) of these developed chronic norovirus infection. Chronic norovirus infection was found among allogeneic heart, kidney and lung transplant recipients. The median shedding period at the end of the study period was 218 days (range 32-1164 days).nnnCONCLUSIONSnThis study shows that chronic norovirus infection is not a rare phenomenon among SOT recipients in a tertiary-care hospital. Further research is needed to study the risk of norovirus transmission to other immunocompromised patients in the hospital and to the general population.

Prominent HLA-G expression in liver disease but not after liver transplantation

Background HLA-G is a nonclassical MHC class I molecule and its physiological expression restricted to placental extravillous trophoblasts contributes to maternal tolerance to the semiallogeneic fetus. Aberrant expression of HLA-G in human organ grafts has been proposed to contribute to graft acceptance. Methods We studied HLA-G expression in liver tissue and serum of adult liver transplant recipients before, early, and late after transplantation in relation to liver function and operational tolerance. Results Cirrhotic explant livers showed robust HLA-G expression on hepatocytes, whereas the majority of noncirrhotic livers and graft biopsies taken before or after liver transplantation (LTX) showed no, or weak, HLA-G expression. The HLA-G expression was induced on hepatocytes in vitro by TGF-&bgr;, but not by other relevant cytokines. Serum levels of the HLA-G isoforms 1 + 5 gradually declined after LTX. Early after LTX, serum HLA-G levels were higher in patients with acute rejection episodes than nonrejectors. Late after LTX, serum HLA-G levels did not differ between operationally tolerant patients and patients on regular immunosuppressive therapy. Conclusions Our data do not support a graft-protective role for HLA-G after LTX, but show that end-stage liver diseases are associated with HLA-G expression on hepatocytes, which may determine a negative feedback to protect the liver against immunological damage.

Everolimus With Reduced Tacrolimus Preserves Long-Term Renal Function in Liver Transplant Recipients: 36 and 48 Months Results From The H2304E1 Study.: Abstract# 2187

2187 Everolimus With Reduced Tacrolimus Preserves Long-Term Renal Function in Liver Transplant Recipients: 36 and 48 Months Results From The H2304E1 Study. J. Fung, F. Saliba, G. Kaiser, L. De Carlis, H. Metselaar, F. Nevens, C. Duvoux, P. De Simone, L. Fischer, G. Dong, B. Rauer, G. Junge. H2304E1 Study Group, Cleveland. Purpose: Preserving long-term renal function in liver transplant recipients (LTxRs) remains a major concern. This study evaluates if early introduction of everolimus (EVR) with reduced tacrolimus (rTAC) provides long-term renal benefi ts in LTxRs. Methods: Patients who completed the 24 month (M) randomized H2304 study could continue their assigned treatment regimen during the 12M extension study (H2304E1): EVR+rTAC (N=106, EVR C0 3-8 ng/mL; TAC C0 3-5 ng/mL) or TAC-C (N=125, C0 6-10 ng/mL). In the extension phase, patients in the EVR+rTAC arm were studied for 12M followed by an additional 12M follow-up on the same regimen. Key primary endpoint was renal function assessed by estimated GFR (eGFR) using MDRD4. Additionally, evolution of renal function from M24 to M36 was explored using a mixed-effect model for longitudinal data. Results: At M36, the EVR+rTAC arm had lower incidence of composite effi cacy failure (11.5% vs 14.6% in TAC-C, risk difference -3.2%, 97.5% CI: -10.5, 4.2; p=0.334). Renal function (mean eGFR) was superior with EVR+rTAC vs TAC-C (78.7 vs 63.5 mL/min/1.73m2) with a difference of 15.2 mL/min/1.73m2 in favor of the EVR+rTAC arm (p<0.001; all extension patients). Proportion of patients with eGFR <60 mL/min/1.73m2 was signifi cantly lower with EVR+rTAC (28.0% vs 42.6% in TAC-C, p=0.032). From randomization to M36, decline in eGFR by ≥30% was reported for 20.0% of patients in the EVR+rTAC arm vs 28.7% in the TAC-C arm. At M48, mean eGFR in the EVR+rTAC arm was 80.5 mL/min/1.73m2 and the number of patients with eGFR <60 mL/min/1.73m2 decreased to 15%. From M24 to M36, longitudinal data analysis for eGFR showed no change in renal function for the EVR+rTAC arm vs a decrease for TAC-C arm (0.04 vs -0.26 mL/min/1.73m2/month). Fewer patients in the EVR+rTAC vs TAC-C arm experienced renal failure (2 vs 10) and renal impairment (1 vs 3) with none vs 2 patients discontinuing study medication due to these adverse events. Proteinuria (≥3 g/day) was not reported in either arm. Conclusion: Early introduction of EVR to reduce TAC exposure preserves longterm renal function in LTxRs. The 48M data show that a notable renal function was maintained for patients on EVR with rTAC. DISCLOSURE: Fung, J.: Other, Novartis, Advisory Committee, Vital Therapies, Consultant. Saliba, F.: Grant/Research Support, Novartis, Astellas, Roche and Gambro, Speaker’s Bureau, Schering Plough, MSD and Gambro, Other, Novartis, Astellas, Roche, Genzyme, Advisory committee, Viropharma and Vital Therapies, Advisory committee. Kaiser, G.: Grant/Research Support, Novartis, Astellas, Roche and Pfi zer. Metselaar, H.: Grant/Research Support, Astellas, Biotest and Novartis, Speaker’s Bureau, Astellas, Biotest and Novartis. Nevens, F.: Grant/ Research Support, Ipsen, Roche, MSD, Jansen, CAF, Astellas, Ferring, Eumedica, and Boston Scientifi c. Duvoux, C.: Grant/Research Support, Novartis, Astellas and Roche, Speaker’s Bureau, Astellas, Other, Novartis, Data Safety Monitoring board member. De Simone, P.: Other, Novartis, Consultant. Fischer, L.: Grant/Research Support, Novartis, Astellas, Speaker’s Bureau, Gilead Sciences, Other, Novartis, Advisory committee. Dong, G.: Employee, Novartis. Rauer, B.: Employee, Novartis. Junge, G.: Employee, Novartis. Abstract# 2188 Liver Allograft Provides Immunoprotection Against Both Acute Cellular Immunity and Chronic Humoral Injury in Simultaneous Liver-Kidney (SLK) Transplantation. T. Taner, J. Heimbach, M. Stegall. Mayo Clinic, Rochester, MN. In SLK, the liver appears to protect the kidney from antibody-mediated injury (AMR), however its ability to protect against cell-mediated or chronic injury are less clear. The goal of this study was to compare SLK to kidney transplant (KT) recipients by assessing the; 1) incidence of acute cellular (ACR) and AMR (both clinical and subclinical), and 2) chronic changes seen in kidney allograft protocol biopsies up to 5-yr after transplantation. Methods: 68 SLK recipients were matched (age, race and sex) with 128 KT recipients. Demographic, laboratory, protocol kidney biopsy (4 mo, 1-, 2and 5-yr) and donor-specifi c HLA antibody (DSA) (baseline, 4 mo, 1-yr and yearly thereafter) data were reviewed. Maintenance immunosuppression dose was lower in KT. 232 kidney biopsies in SLK (median 3, range 1-9) and 487 in KT (median 4, range 1-9) were reviewed; incidence of events analyzed by Kaplan-Meier. Mean follow up was 67 months (±40) in both groups. Results: Patient survival was 89.7 vs 85.2%, kidney graft survival was 82.4 vs 70.3%, in SLK and KT, respectively. Four kidney grafts were lost to rejection in KT (2 ACR, 1 AMR, 1 both), none in SLK. The median eGFR at 1and 5-yr were 53 and 53 in SLK; 52 and 48 in KT. Humoral alloimmunity: DSA (MFI>2000) was present at transplant in 14 SLK (10 with +XM, 14.7%) and 7 KT (all with +XM, 5.5%). One patient in each group had persistent class II DSA post-transplant. De novo DSA, predominantly class II, was found in 11 SLK and 9 KT recipients. Patients with de novo DSA were more likely to be non-compliant (5/11 in SLK and 6/9 in KT), and have liver graft dysfunction in SLK (6/11). 5-yr cumulative incidence of AMR was similar in SLK (7.4%) and KT (9.4%). Cellular immunity: ACR was signifi cantly rarer in SLK (7.4%) than in KT (28.9%) (P=0.001).Most of the ACR were subclinical (80% in SLK and 69% in KT). Chronic changes at 5-yr were similar in SLK vs KT (interstitial fi brosis 27.9 vs 22.7%; arteriolar hyalinosis 13.2 vs 14.1%). Importantly, chronic glomerulopathy (usually associated with humoral injury) was more common in KT at 5-yr (8.6% vs 1.5%, P=0.06). Conclusions: Compared to KT, SLK appears to be associated with lower rates of ACR and fewer chronic changes associated with 2188 Liver Allograft Provides Immunoprotection Against Both Acute Cellular Immunity and Chronic Humoral Injury in Simultaneous Liver-Kidney (SLK) Transplantation. T. Taner, J. Heimbach, M. Stegall. Mayo Clinic, Rochester, MN. In SLK, the liver appears to protect the kidney from antibody-mediated injury (AMR), however its ability to protect against cell-mediated or chronic injury are less clear. The goal of this study was to compare SLK to kidney transplant (KT) recipients by assessing the; 1) incidence of acute cellular (ACR) and AMR (both clinical and subclinical), and 2) chronic changes seen in kidney allograft protocol biopsies up to 5-yr after transplantation. Methods: 68 SLK recipients were matched (age, race and sex) with 128 KT recipients. Demographic, laboratory, protocol kidney biopsy (4 mo, 1-, 2and 5-yr) and donor-specifi c HLA antibody (DSA) (baseline, 4 mo, 1-yr and yearly thereafter) data were reviewed. Maintenance immunosuppression dose was lower in KT. 232 kidney biopsies in SLK (median 3, range 1-9) and 487 in KT (median 4, range 1-9) were reviewed; incidence of events analyzed by Kaplan-Meier. Mean follow up was 67 months (±40) in both groups. Results: Patient survival was 89.7 vs 85.2%, kidney graft survival was 82.4 vs 70.3%, in SLK and KT, respectively. Four kidney grafts were lost to rejection in KT (2 ACR, 1 AMR, 1 both), none in SLK. The median eGFR at 1and 5-yr were 53 and 53 in SLK; 52 and 48 in KT. Humoral alloimmunity: DSA (MFI>2000) was present at transplant in 14 SLK (10 with +XM, 14.7%) and 7 KT (all with +XM, 5.5%). One patient in each group had persistent class II DSA post-transplant. De novo DSA, predominantly class II, was found in 11 SLK and 9 KT recipients. Patients with de novo DSA were more likely to be non-compliant (5/11 in SLK and 6/9 in KT), and have liver graft dysfunction in SLK (6/11). 5-yr cumulative incidence of AMR was similar in SLK (7.4%) and KT (9.4%). Cellular immunity: ACR was signifi cantly rarer in SLK (7.4%) than in KT (28.9%) (P=0.001).Most of the ACR were subclinical (80% in SLK and 69% in KT). Chronic changes at 5-yr were similar in SLK vs KT (interstitial fi brosis 27.9 vs 22.7%; arteriolar hyalinosis 13.2 vs 14.1%). Importantly, chronic glomerulopathy (usually associated with humoral injury) was more common in KT at 5-yr (8.6% vs 1.5%, P=0.06). Conclusions: Compared to KT, SLK appears to be associated with lower rates of ACR and fewer chronic changes associated with DSA, although SLK recipients had a higher prevalence of DSA pretransplant and were maintained on lower doses of immunosuppression; suggesting that in SLK, the liver appears to provide immunoprotection against both acute cellular immunity and chronic humoral injury.

26 EVEROLIMUS-BASED IMMUNOSUPPRESSION PROVIDES SUPERIOR RENAL FUNCTION AND COMPARABLE EFFICACY VERSUS STANDARD TACROLIMUS IN DE NOVO LIVER TRANSPLANT RECIPIENTS: 24-MONTH RESULTS OF A RANDOMISED CONTROLLED TRIAL

26 EVEROLIMUS-BASED IMMUNOSUPPRESSION PROVIDES SUPERIOR RENAL FUNCTION AND COMPARABLE EFFICACY VERSUS STANDARD TACROLIMUS IN DE NOVO LIVER TRANSPLANT RECIPIENTS: 24-MONTH RESULTS OF A RANDOMISED CONTROLLED TRIAL F. Nevens, L. De Carlis, H.J. Metselaar, G.M. Kaiser, F. Saliba, S. Jonas, C. Duvoux, G. Dong, G. Junge, P. Lopez, P. De Simone. Hepatology, UZ Leuven, Leuven, Belgium; Niguarda ‘Ca Granda’ Hospital, Milan, Italy; Erasmus MC, University Hospital Rotterdam, Rotterdam, The Netherlands; Univ.-Klinikum Essen, Essen, Germany; Hopital Paul Brousse, Villejuif, France; University Medical Center Leipzig, Leipzig, Germany; Hopital Henri Mondor, Creteil, France; Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA; Novartis Pharma AG, Basel, Switzerland; Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy E-mail: frederik.nevens@uzleuven.be

P0983 : Association between macro-nutrient intake and presence of nonalcoholic fatty liver disease in the Rotterdam study: a population-based study

Background and Aims: Nonalcoholic fatty liver disease (NAFLD) is associated with coronary artery calcification and increased prevalence of cardiovascular disease in many cross-sectional studies. However, whether NAFLD per se affect the progression of coronary artery calcification still remains to be elucidated. The aim of this study was to investigate the prospective association between NAFLD and the incidence and progression of coronary artery calcification (CAC) in a longitudinal cohort study. Methods: Among 1732 subjects who underwent serial CAC score evaluation, we evaluated 847 subjects with NAFLD and 885 subjects without NAFLD. Only those without viral hepatitis, significant alcohol consumption and known coronary artery disease were enrolled. NAFLD was diagnosed by ultrasonography in subjects without significant alcohol consumption. CAC score was evaluated by the Agatston method with multi-detector computed tomography. Results: The baseline CAC score was higher in those with NAFLD, and greater number of these subjects showed progression (48.8% vs. 38.4%, p < 0.001 in subjects with vs. without NAFLD). NAFLD was prospectively associated with progression of CAC score (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.26–1.85, p < 0.001). Noticeably, the impact of NAFLD significantly varied with the severity of baseline coronary atherosclerosis. In those without calcification at baseline, NAFLD significantly affected progression of atherosclerosis (adjusted OR 1.54, 95%CI 1.05–2.27, p =0.028), after adjustment for age, hypertension diabetes mellitus, dyslipidemia, smoking, gender and body mass index. Analysis according to the severity of NAFLD showed that NAFLD in its more severe form promotes progression of CAC (adjusted OR 1.77, 95%CI 1.08–2.88, p =0.022). However, in subjects with baseline CAC, NAFLD did not affect progression of CAC (p =0.482). Conclusions: NAFLD plays a role in early stage of coronary atherosclerosis, and it also seems that greater degree of NAFLD affects the progression independent of traditional risk factors. Thus NAFLD does not solely show a simple association, but also plays a role in the development and progression of coronary artery disease.