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Contact Information:

Ms Jurate Wall


Study Location:

King's College Hospital (lead)
London
SE5 9RS


Liver immunosuppression free trial ("LIFT"), version 1

Not Recruiting

Open to: All Genders

Age: Adult

Medical Conditions

Topic: Hepatology
Subtopic: Hepatology
Disease: All Hepatology


Study summary

Background and study aims
Following liver transplantation patients need to be given powerful drugs (known as immunosuppressive medication), to prevent organ rejection. These drugs are usually given for the rest of the patients life, which can result in important side effects. This the main reason why in the long run transplanted patients die more frequently than non-transplanted healthy individuals. Not all liver transplant patients, however, require lifelong immunosuppressive medication. Some of them develop a phenomenon known as operational tolerance and can discontinue this medication without rejecting the transplanted liver. In tolerant patients the withdrawal of anti-rejection medication could increase their survival and improve their quality of life. However, until now there have been no tests to identify tolerant patients before immunosuppression medication is stopped. Our research group recently identified a genetic test of tolerance in liver biopsies that can predict the outcome of immunosuppressive drug withdrawal. This test could radically change the long-term care of liver transplant patients.

Who can participate?
Liver transplant patients that received their new liver more than 3 years ago or more than six years ago if aged 18-49 or at least 50 years old respectively.

What does the study involve?
Participants first have a liver biopsy for the genetic test of tolerance. They are then randomly allocated to one of two groups. Patients randomized to group 1 are offered drug withdrawal regardless of the result of the genetic test. Patients randomized to group 2 undergo drug withdrawal if the genetic test is positive, and continue the immunosuppressive medication if the test is negative. By comparing the outcome of the 2 groups we will determine how much the test can benefit transplanted patients.

What are the possible benefits and risks of participating?
Chronic immuno-suppression (IS) is associated with a variety of life threatening side effects following liver transplantation, including infection, malignancy, hypertension, diabetes, nephrotoxicity and cardiovascular diseases. Calcineurin inhibitor induced nephrotoxicity, in particular, is responsible for a significant rate of chronic renal failure, need for renal replacement therapy and increased mortality. Elimination of calcineurin inhibitors may preserve waning renal function and avoid the associated morbidity and mortality risk.Identification of a reproducible and reliable tolerance signature will allow tailoring of IS to individual patient characteristics. It may also identify critical pathways responsible for the tolerant state that can be therapeutically exploited to induce tolerance in those who do not achieve it spontaneously. While there is abundant information in the literature suggesting that in carefully selected liver recipients IS withdrawal is feasible and safe, the procedure is not without risk, as it can induce immunologically-mediated allograft rejection. In this regard, the main risks of IS withdrawal are acute and/or chronic rejection, silent development of allograft fibrosis, potential complications associated with the need to increase IS to treat rejection episodes; and graft loss or patient mortality.

Where is the study run from?
King's College London (UK)

When is the study starting and how long is it expected to run for?
August 2015 to October 2017

Who is funding the study?
National Institute for Health Research (UK)

Who is the main contact?
Ms Jurate Wall

The objective of this study is to determine if a genetic test of tolerance in liver biopsies can be employed to optimize immunosuppression withdrawal, so that withdrawal is only performed in patients who have developed tolerance.


Randomised; Interventional; Design type: Treatment

Key dates

The recruitment start and end dates are as follows:

01 Aug 2015

01 Oct 2017

Study type

Interventional

Intervention Type : Other
Intervention Name :
Intervention Description : Adult liver transplant recipients will undergo gradual IS withdrawal following randomisation 1:1 to either: 1. Non-Biomarker-based IS weaning (Arm A)2. Biomarker-based IS weaning (Arm B). Participants allocated to Arm B will be offered IS withdrawal only if they are classified as tolerant on the basis of a biomarker test (Arm B+), while they will remain on maintenance IS if classified as non-tolerant (Arm B-)


Who can take part?

You can take part if:


Current participant inclusion criteria as of 29/01/2019:1. At the time of screening: more than 3 years post-transplant if participants are ≥50 years old, OR ≥ 6 years post-transplant if participant age is ≤50 years old. 2. Recipient of either deceased or living donor liver transplant. 3. Recipient of single organ transplant only 4. Liver function tests: direct bilirubin ≤17.1 umol/L and ALT ≤60 IU/L at the screening visit. 5. On calcineurin inhibitor (CNI) IS with or without one of the following: Low dose mycophenolic acid (≤ 1080 mg daily), mycophenolate mofetil (MMF ≤ 1500 mg daily), azathioprine (≤ 150 mg daily), sirolimus/everolimus; or on monotherapy with sirolimus/everolimus or mycophenolate/mycophenolic acid monotherapy (effective contraception must be used before beginning mycophenolate therapy, during therapy, and for six weeks following discontinuation of therapy, see Appendix 6), 6. Ability to sign informed consent.

Previous participant inclusion criteria:1. At the time of screening: more than 3 years post-transplant if participants are ≥50 years old, OR ≥ 6 years post-transplant if participant age is 18-49 years old.2. Recipient of either deceased or living donor liver transplant3. Recipient of single organ transplant only4. Liver function tests: direct bilirubin =17.1 umol/L and ALT =60 IU/L at the screening visit.5. On calcineurin inhibitor (CNI) based maintenance IS and no more than one of the following: Low dose mycophenolic acid (= 1080 mg daily), mycophenolate mofetil (MMF = 1500 mg daily), or azathioprine (= 150 mg daily); or on mycophenolate/mycophenolic monotherapy (effective contraception must be used before beginning mycophenolate therapy, during therapy, and for six weeks following discontinuation of therapy)6. Ability to sign informed consent




You may not be able to take part if:

Current participant exclusion criteria as of 29/01/2019:1. Serum positivity for HCV-RNA 2. Serum positivity for HIV-1 infection, HBV surface antigen or HBV-DNA 3. Immune-mediated liver disease in which IS discontinuation is inadvisable (autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cirrhosis). 4. Acute or chronic rejection within the 52 weeks prior to screening. 5. GFR <30 mL/min (to mitigate the risk of worsening renal failure should rejection occur and high level of CNI be required). 6. The need for chronic anti-coagulation that cannot be safely discontinued to safely perform for a liver biopsy. 7. Baseline (screening) liver biopsy showing any of the following: a) acute rejection according to Banff criteria; b) early or late chronic rejection according to Banff criteria; c) inflammatory activity and/or fibrosis in excess of permissive criteria (Table 1) (25); f) any other findings that might make participation in the trial unsafe. Eligibility will be determined by the central pathologist. 8. Patient age <18 years old at the time of transplant. 9. Pregnant females and females of childbearing age not using effective contraception (See Appendix 6). 10. Current illicit drug or alcohol abuse. 11. Inability to participate in frequent monitoring of liver function (every 3 weeks) and clinical visits during IS withdrawal. 12. Inability to comply with study directed treatment. 13. Any medical condition that in the opinion of the principal investigator would interfere with safe completion of the trial. 14. Participation in another clinical trial during the month prior to enrolment.

Previous participant exclusion criteria:1. HCV infection (defined by serum positivity for HCV-RNA)2. Positive serology for HIV-1, hepatitis B surface antigen, or hepatitis B DNA3. Immune-mediated liver disease in which IS discontinuation is inadvisable (autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cirrhosis)4. Acute or chronic rejection within the 52 weeks prior to screening5. GFR <40 mL/min (to mitigate the risk of worsening renal failure should rejection occur and high level of CNI be required)6. The need for chronic anti-coagulation that cannot be safely discontinued for a minimum of 1 week to safely perform for a liver biopsy7. Baseline (screening) liver biopsy showing any of the following:7.1. Acute rejection according to Banff criteria7.2. Early or late chronic rejection according to Banff criteria7.3. Moderate-severe fibrosis (Ishak stage 3 or more)7.4. Chronic hepatitis (defined as predominantly mononuclear portal inflammation with or without plasma cells) with moderate/marked portal inflammation (Ishak 3 or more) or with mild/moderate interface hepatitis (Ishak 2 or more)7.5. Perivenular necro-inflammatory activity in a majority of terminal hepatic venules7.6. Any other findings that might make participation in the trial unsafe. Elligibility will be determined by the central pathologist8. Pregnant females and females of childbearing age not using effective contraception9. Current illicit drug or alcohol abuse10. Inability to participate in frequent monitoring of liver function (every 3 weeks) and clinical visits during IS withdrawal11. Inability to comply with study directed treatment12. Any medical condition that in the opinion of the principal investigator would interfere with safe completion of the trial


Where can I take part?

Below are the locations for where you can take part in the trial.

  • King's College Hospital (lead)
    London
    SE5 9RS

Contact information

Ms Jurate Wall


Funders/Sponsors


The study is sponsored by King's College London and funded by National Institute for Health Research .



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for Trial ID: ISRCTN47808000

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