*Purpose: The purpose of this study is to evaluate the effects of the timing of everolimus transition on renal outcomes in liver transplant recipients.

*Methods: This retrospective review included adult liver transplant recipients from 01/01/2013 to 05/31/2018. Patients transitioned to everolimus were included in this subgroup analysis. Patients were separated into groups based upon timing of transition: group 1 (<90 days), group 2 (91-180 days), group 3 (181-365 days), and group 4 (>365 days). The primary outcome was renal function (creatinine clearance (CrCl) per Cockcroft-Gault equation) at 1 month post-transition compared to baseline. Secondary outcomes included renal function at 12 months post-transition and biopsy proven acute rejection (BPAR) following conversion. Paired t-tests were used for analysis.

*Results: Of 350 adult liver transplants during the study period, eighty patients were transitioned to everolimus in combination with other immunosuppression or as monotherapy according to physician discretion. Group 1 included 25 patients, group 2 had 20, group 3 had 19, and group 4 had 16. The average age was 56.2 years; the majority were male (67.5%) and Caucasian (90%). The most common indications for transplant were nonalcoholic steatohepatitis (26.3%), hepatitis C virus (25%), and alcohol (23.8%). Hepatocellular carcinoma was present in 27.5% of patients. Average MELD and MELD-NA was 22.8 and 24.2, respectively. Renal sparing induction with antithymocyte globulin occurred in 37.5%. Group 1 had a mean CrCl 45.4 ml/min at time of transition, which significantly improved at 1 month and 12 months (69.6 and 61.6 ml/min, p=0.004 and 0.035). Group 2 had mean CrCl 43.9 ml/min at time of transition, which also significantly improved at 1 month and 12 months (60.7 and 57.5 ml/min, p=0.02 and 0.008). Group 3 had a mean CrCl 52.6 ml/min at time of transition, which significantly improved at 1 month but not at 12 months (63.8 and 55.2 ml/min, p=0.0004 and 0.43). Group 4 had a mean CrCl 54.6 ml/min at time of transition and did not show renal improvement at 1 month or 12 months (58.6 and 49.6 ml/min, p=0.2 and 0.84). BPAR occurred in 40% of group 1, 20% of group 2, 10.5% of group 3, and 6.25% of group 4. Median time to rejection (days) following transition for each group was 87.5, 108, 220.5, and 85, respectively.

*Conclusions: Early everolimus conversion (less than 180 days) showed improvement in renal function in adult liver transplant recipients, while later transition did not show the same sustained renal benefit. Early transition also showed higher rates of BPAR. Our data would suggest conversion was optimal for renal function and BPAR rates 181-365 days from transplant. Timing of everolimus transition must balance the risk of rejection with the benefit of renal improvement.

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