a meta-analysis of randomised

(1)

Conversion from calcineurin to mammalian target of rapamycin inhibitors in liver transplantation: a meta-analysis of randomised controlled trials

Thomas E Glover, Christopher JE Watson, Paul Gibbs, J Andrew Bradley, Evangelia E Ntzani, Vasilis Kosmoliaptsis

Supplementary Information Data extraction

Data extraction was performed independently by 2 investigators (TG and EEN) and discrepancies were resolved by a third investigator (VK).

We recorded information on study characteristics and demographics, including authors, publication year and journal, sample size per-arm, population characteristics, treatment indication, CNI dose, mTORi characteristics (bolus and maintenance dose, mode of administration, timing of intervention, abrupt cessation or tapering of previous immunosuppression) and study duration. The primary meta-analysis outcome was renal function (estimated Glomerular Filtration Rate, GFR or creatinine clearance, CrCl) at 12 months and secondary outcomes included acute

rejection, graft loss, patient survival and adverse events. All outcomes were analysed at one year post-randomisation; longer term outcomes, if

available, were analysed for the latest time-point.

(2)

Assessment of methodological quality

The methodological quality of included trials and the risk of bias were assessed by using elements included in the Cochrane Collaboration’s tool for assessing risk of bias (1). The domains used in the present systematic review pertained to randomisation and allocation concealment

(selection bias), blinding (performance and detection bias), loss to follow-up and adherence to the intention-to-treat principle (attrition bias). We chose to present the meta-analysis of all studies while providing a summary of the risk of bias across studies.

Data synthesis and statistical analysis

For each trial we retrieved or calculated the crude risk ratio (RR) estimates and corresponding 95% confidence intervals (CI) for the assessed

binary outcomes (acute rejection, graft loss, patient survival and adverse events), and the mean difference (MD) and corresponding standard

deviation (SD) for the assessed continuous outcomes (GFR). We also used the standardised mean difference (and 95% CI), which expresses the

mean score difference in SD units, and can be used to directly compare different scales or scores across the individual studies. The presence of

statistically significant heterogeneity was assessed by the Q statistic (significant at p<0.10) and the extent of the observed heterogeneity was

assessed by the I

²

(ranging from 0% to 100%). The overall summary MD, SMD and RR effect sizes were estimated using both fixed and random

effects models. Analyses performed using these models yielded similar results. We chose to report summary estimates using random-effects

models because, in the presence of heterogeneity, they provide more conservative estimates. Summary effect estimates for renal function, acute

rejection, graft loss and patient survival were based on intention-to-treat (ITT) populations as reported in the study publications; moreover, all

(3)

eligible studies reported adverse events for the safety population and, therefore, summary effect sizes for adverse events were estimated based on safety populations as reported in the study publications.

Pre-specified subgroup analyses were performed to explore sources of heterogeneity; studies were stratified by time of conversion to mTORi (early versus late conversion, defined as ≤6 months after transplantation) or by type of mTORi (sirolimus versus everolimus). Sensitivity analyses were performed excluding trials evaluating CNI minimization (2, 3) and trials evaluating steroid elimination regimens (3). To further explore moderators of the observed effect estimates, a meta-regression analysis was performed accounting for baseline renal function. Small study effects (indicating publication bias) were assessed by visual examination of funnel plots per outcome and by using the Begg-Mazumbar test. Where information was missing we contacted the authors to request the relevant data. If the SD for a particular outcome was not reported, it was estimated post hoc based on standard formulae. To enable meaningful interpretation of renal function analysis, SMD was back-transformed into familiar units (GFR expressed in mL/min/1.73m

²

) by multiplication of the SMD by the baseline standard deviation (of mean GFR) reported in the largest included trial by Abdelmalek et al (4).

Table S1. Literature search algorithm

[(calcineurin inhibitor OR cyclosporine OR ciclosporin* OR neoral* OR sandimmun* OR tacrolimus OR FK506 OR FK 506 OR prograf OR

advagraf OR adoport) AND (rapamycin derivative OR rapamune OR sirolimus OR mtor inhibitor or mTORC1 inhibitor OR TOR inhibitor OR

(4)

mammalian target of rapamycin OR rapamycin* OR everolimus OR RAD OR SDZRAD OR RAD001) AND (liver OR hepatic) AND (transplant OR transplantation OR graft OR graf OR transplant*)]

Table S2. Characteristics of included studies

Study ID Study design Time to conversion since transplant

Graft function at time of randomization

Immunosuppressive dosing regime Outcomes reported

Method of switching

Pre- conversion

Intervention Comparator CNI in the intervention

arm after switching

GFR Serum creatini ne

Protein uria

Mort ality

Graft loss

Rejecti on

Malign ancy

AEs

Watson 2007 Open-label RCT of conversion from CNI to SRL in maintenance liver transplant recipients (N=27)

Late Median 3.05 years (IQR = 0.88-7.4 years)

Adult liver transplant recipients 6 months post-transplant, suboptimal renal function:

eGFR<65ml/min (MDRD)

Baseline measured GFR (mean;SD):

55.7;10.2ml/min (SRL) 48.4;15.8ml/min (CNI)

Abrupt CsA TAC Prednisolone Azathioprine

SRL, bolus:

none, target levels:

5-15 ng/mL (N=13)

CsA¹ TAC Prednisolone Azathioprine (N=14)

None        

Shenoy 2007 Single-centre, prospective RCT of conversion from CNI to SRL in maintenance liver transplant recipients (N=40)

Late Mean 4.4 years Range 0.5- 11 years

Adult liver transplant recipients with stable liver function and renal dysfunction: CrCl 40- 80ml/min (24-hour urine excretion of creatinine)

Baseline CrCl (mean;SD):

64;18ml/min (SRL) 60;12ml/min (CNI)

Tapered CsA TAC Prednisone MMF Azathioprine

SRL, bolus:

5mg, target levels: 6- 10ng/ml (N=20)

CsA² TAC Prednisone MMF Azathioprine (N=20)

CsA + TAC discontinued

over 1-2 weeks

    

(5)

Mort ality

Graft loss

Rejecti on

Malign ancy

AEs

De Simone 2009

Multi-centre, open-label RCT of conversion from CNI to EVR in maintenance liver transplant recipients (N=145)

Late Mean 3.3 years; SD 1.7 Range 1.1- 10.9 years

Adult liver transplant from a deceased or living donor 12-60 months prior to study, eligible for study if CrCl 20-60ml/min³ (Cockcroft-Gault)

51.0;11.7ml/min (EVR) 50.3;11.3ml/min (CNI)

Abrupt CsA

TAC MPA Azathioprine Steroids

EVR, bolus:

none, target levels: 6- 12ng/ml Steroids (N=72)

CsA⁴ TAC MPA Azathioprine Steroids (N=73)

CsA + TAC⁵     

Eisenberger 2009

Single-centre, RCT of conversion from CNI to SRL in liver transplant recipients (N=16)

Late Median 50 months Range 6- 132 months

Stable liver transplant patients, transplanted 6-120 months prior to study with renal impairment: CrCl 40- 90ml/min (Cockcroft- Gault)

55.4;24ml/min (SRL) 66.9;17ml/min (CNI)

Abrupt CsA

TAC Steroids MMF

SRL, bolus:

10-15mg, target level:

6-16ng/ml Steroids MMF (N=8)

CsA⁶ TAC Steroids MMF Azathioprine (N=8)

None     

(6)

Mort ality

Graft loss

Rejecti on

Malign ancy

AEs

Masetti 2010 Single centre open-label RCT of CNI withdrawal and EVR

monotherapy in liver transplant recipients (N=78)

Early 10 days

Adult liver transplant recipients with a maximum cold ischaemia time of 12 hours, patients with renal failure at randomisation were excluded (eGFR ≤29 mL/min/1.73 m², MDRD)

Baseline GFR (MDRD, mean;SD):

Tapered CsA Prednisone Basiliximab

EVR, bolus:

none, target level: 6- 12ng/ml⁷ Prednisone⁸ (N=52)

CsA⁹ MMF Prednisone⁸ (N=26)

CsA¹⁰     

Abdelmalek 2012

Open-label RCT of conversion from CNI to SRL in liver allograft recipients (N=607)

Late 4.0;2.9 years (mean;SD)

Recipients 13 years of age, transplanted within 6 months to 12 years from randomisation, baseline cGFR 40- 90ml/min (Cockcroft- Gault)¹¹

Baseline GFR (mean;SD):

Abrupt CsA

TAC MMF or Azathioprine Steroids

SRL, bolus:

10-15mg (divided dose), target level: 6- 16ng/ml¹² (N=393)

CsA¹³ TAC MMF or Azathioprine Steroids (N=214)

None       

(7)

Mort ality

Graft loss

Rejecti on

Malign ancy

AEs

De Simone 2012

Multi-centre, three-arm, prospective, open-label RCT of CNI elimination and EVR initiation in liver transplant recipients (N=719)¹⁴

Early 30±5 days

Adult deceased donor liver transplant patients with acceptable graft function and

eGFR30ml/min/1.73m² (MDRD4), absence of rejection before randomisation

Baseline GFR (CKD-EPI, mean;SD):

Tapered TAC Prednisolone MMF

EVR, bolus:

none, target level: 3- 10ng/ml¹⁵ Prednisolone (N=231)

TAC¹⁶ Prednisolone¹⁷ (N=243)

TAC, eliminated gradually by end of month

4 post liver transplant

      

PROTECT Open-label RCT of conversion from CNI to EVR after liver transplantation (N=203)

Early 43.1;11.3 days (mean;SD)

Adult liver allograft recipients, 4 weeks of prior CNI treatment, rejection-free at least 2 weeks prior to randomisation, sufficient renal function (cGFR >50ml/min, Cockcroft-Gault)

Baseline GFR (mean;SD):

83.5;27ml/min (EVR) 83.2;29.1ml/min (CNI)

Tapered CsA TAC Steroids Basiliximab

EVR, bolus:

none, target level: 5- 12ng/ml¹⁸ Steroids (N=101)

TAC¹⁹ CsA Steroids (N=102)

CsA + TAC²⁰       

(8)

Mort ality

Graft loss

Rejecti on

Malign ancy

AEs

SPARE THE NEPHRON

Open-label RCT of conversion from CNI to SRL in maintenance liver transplant recipients (N=294)

Early 53.9;12.8 days (mean;SD)

Adult liver transplant recipients, patients with calculated eGFR<30 mL/min within 1 week prior to randomisation were excluded (MDRD- 6)

Baseline CrCl (Cockcroft- Gault, mean;SD):

Abrupt CsA TAC MMF Steroids ATG Basiliximab Daclizumab

SRL, bolus: 2- 4mg, target level: 5- 10ng/ml MMF Steroids ATG (N=148)

CsA²¹ TAC MMF Steroids ATG (N=146)

None    ²² ²²   

Villamil 2014 Randomised, multicentre, open-label RCT of conversion from CNI to EVR in patients with HCV infection (N=43)

Late 4.4±3.6 years (mean;SD)

Adult liver transplant recipients, patients 6 months post liver transplant with recurrent HCV infection and histologically confirmed liver fibrosis at study entry or <6 months before trial, patients excluded if rejection <6 months before trial start, multi- organ transplant recipients, HCV recurrence or on anti- HCV treatment

Baseline GFR (MDRD, mean;SD):

Tapered CsA TAC MMF Steroids

EVR, bolus:

none, target level: 6 to 12ng/ml²³ Steroids (N=22)

CsA²⁴ TAC MMF²⁵ Steroids (N=21)

None     

(9)

1TAC patients median 12-hour trough concentrations 7.7ng/ml (3 months) and 7.0ng/ml (12 months); 2 CsA patients had trough levels of 86ng/ml and 107ng/ml at 3 months

2Target range not specified but mean CsA dose 166±60mg/day during study period. CsA levels 150±48ng/dL at baseline and 163±74ng/dL at 12 months

3Patients required to have been on tacrolimus (C0 level of 3-8ng/ml) or CsA (C0 level of 50-150ng/ml or a C2 level of 250-650ng/ml)

4Target ranges not specified but at baseline, TAC median C0 level 5.5ng/ml and CsA median C0 level 105.5ng/ml. At 6 months, TAC median C0 level 4.2ng/ml and CsA median C0 level 64.5ng/ml (CNI dose reductions in CNI control group)

5CsA + TAC reduced by 50% with each visit if EVR C0 level 3ng/ml & CrCl <10ml/min greater than baseline value. 50% dose reductions were continued until no longer possible and then stopped

6Target ranges not specified but CsA concentration at baseline 160;46ng/ml (mean;SD) and at 12 months 150;57ng/ml (mean;SD), TAC concentrations in 2 patients at baseline 10.8 and 5.8ng/ml and at 12 months 11.1 and 8.0ng/ml

7EVR 6-10ng/ml (days 10-30), 8-12ng/ml (day 30 to end of month 6), 6-10ng/ml after month 6

8Prednisone given to all patients in EVR arm until 35 days post-transplant

9CsA target levels were 225±25ng/ml (days 0-30), 200±25ng/ml (day 30 to end of month 6) and 150±25ng/ml (after month 6)

10CsA target levels 100±25ng/ml until day 30 then abruptly stopped

11Patients must have been on a stable immunosuppressive regimen of the same CNI (CsA or TAC) or a combination of CNI with steroids and/or antimetabolite therapy for 4 weeks prior to randomization, no prior use of SRL or any of its derivatives, no evidence of thrombosis or clinically significant stenosis of the hepatic artery, hepatic vein or portal vein

12Modified to 8-16ng/ml following request of the study’s Data Safety and Monitoring Board

13CsA target level 50-250ng/ml, TAC target level 3-10ng/ml

14Patients randomised into 3 groups (EVR + reduced TAC, TAC elimination and TAC control). Recruitment to the TAC elimination group was stopped 120-180 days after randomisation due to a significantly higher rate of rejection in this arm. We report outcomes for the TAC elimination and TAC control arms.

15EVR target level 3-8ng/ml for first 4 months and 6-10ng/ml thereafter

16TAC target level 8-12ng/ml to end of month 4 and 6-10ng/ml thereafter

17Until at least 6 months post transplant

18EVR target level 5-12ng/ml (TAC patients) and 8-12ng/ml (CsA patients)

19Target ranges not specified but mean dose of CsA 305.5±101.9mg/day, mean dose of TAC 6.6±3.3mg/day

20CsA + TAC gradually reduced over 8 weeks and then stopped (provided patient rejection-free for at least 4 weeks)

21TAC target level 3-10ng/ml and CsA target level 100-250ng/ml

22The Spare the Nephron study reported a composite outcome of graft loss and death.

23EVR concentration range was 7.6-9.0ng/ml, MMF discontinued with CNI

2411 patients on CsA with trough concentration range 96.5-134.8ng/ml, 10 patients on TAC with trough concentraton range 5.3-6.6ng/ml

25In CNI group, 3 patients had concurrent steroids, 4 had concomitant MMF

CsA, cyclosporin; TAC, tacrolimus; CNI, calcineurin inhibitor; SRL, sirolimus; EVR, everolimus; MMF, mycophenolate mofetil; Aza, azathioprine; ATG, antithymocyte globulin; GFR, glomerular filtration rate; CrCl, creatinine clearance; RCT, randomised control trial; OLT, orthotopic liver transplant; HCV, hepatitis C virus, CKD-EPI; chronic kidney disease – epidemiology, MDRD; modified diet in renal disease formula for GFR

(10)

Table S3: Risk of bias in the published controlled trials

Study ID Allocation Sequence Described

Allocation concealment

Blinding Other potential

sources of bias

Handling of missing data

Patient Personnel Assessor

Watson 2007 Random number generation

Yes No No No ITT Clear

Shenoy 2007 1:1 Block design randomisation

NR NR NR NR ITT Clear

De Simone 2009 1:1 Voice response system

NR No No No ITT + safety

populations 80% power

Unclear

Eisenberger 2009 1:1 Randomisation method not reported

NR NR NR Yes¹ ITT Clear

Masetti 2010 2:1 EVR:CNI Computer-based ratio

NR No No No ITT + PP populations Unclear

Abdelmalek 2012 2:1 SRL:CNI Sequential randomisation using blocks of numbers

Clear

De Simone 2012 1:1:1 Randomisation method not reported

NR No No No ITT + PP populations

80-90% power

Clear

PROTECT 1:1 Central computer-based randomisation

NR No No No ITT + PP populations

80% power

Clear

SPARE THE NEPHRON

1:1 Random number generation + voice response system

No No No No ITT + safety + PP

Clear

(11)

Villamil 2014 1:1 Randomised distribution of treatment allocation cards via a central automated system

populations 78% power Slow recruitment led to fewer participants than planned

Clear

1Measurements taken by two experienced physicians and both observers blinded

NR, not reported; ITT, intention to treat population; PP, per-protocol population; CNI, calcineurin inhibitor; SRL, sirolimus; EVR, everolimus

(12)

Table S4: Characteristics of included studies reporting on acute rejection

Study ID mTORi CNI Early/

Late

Definition of rejection

Watson 2007 SRL CsA or TAC Late BPAR

Shenoy 2007 SRL CsA or TAC Late Increase in liver function tests responsive to steroids

De Simone 2009 EVR CsA or TAC Late BPAR

Eisenberger 2009 SRL CsA or TAC Late NR

Masetti 2010 EVR CsA only Early BPAR

Abdelmalek 2012 SRL CsA or TAC Late BPAR

De Simone 2012 EVR TAC only Early BPAR

PROTECT EVR CsA or TAC Early BPAR

SPARE THE NEPHRON SRL CsA or TAC Early BPAR

Villamil 2014 EVR CsA or TAC Late BPAR

CNI, calcineurin inhibitor; mTORi, mammalian target of rapamycin inhibitor; CsA, cyclosporin; TAC, tacrolimus; SRL, sirolimus; EVR, everolimus; NR, not reported; BPAR, biopsy-proven acute rejection

(13)

Table S5. Patients that failed to be randomised and patients that discontinued the allocated treatment in included studies

Study ID Number of patients that failed to be randomised (%)

Number of patients who discontinued allocated treatment in intervention group versus control group (%)

Watson 2007 58/88 (66%) Sirolimus 2/13 (15%)

CNI 0/14 (0%)

Shenoy 2007 0 (0%) Sirolimus 1/20 (5%)

CNI 0/20 (0%)

De Simone 2009 0 (0%) Everolimus 32/72 (44%)¹

CNI 16/73 (22%)

Eisenberger 2009 0 (0%) Sirolimus 1/8 (13%)

CNI 0/8 (0%)

Masetti 2010 4/82 (5%) Everolimus 14/52 (27%)¹

CNI 9/26 (35%)

Abdelmalek 2012 0 (0%) Sirolimus 140/393 (36%)²

CNI 23/214 (11%)

De Simone 2012 99/818³ (12%) Everolimus 127/231 (55%)

CNI 49/243 (20%)

PROTECT 172/375 (46%) Everolimus 50/101 (50%)¹

CNI 39/102 (39%) SPARE THE

NEPHRON

26/332 (8%) Sirolimus 65/149 (44%)⁴

CNI 45/145 (31%)

Villamil 2014 13/56 (23%) Everolimus 5/22 (23%)

CNI 0/21 (0%)

1These studies included patient death as a reason for treatment discontinuation

24/393 (1%) randomised to mTORi and4/214 (2%) randomised to CNI continuation did not receive the allocated treatment. It has been assumed that these 8 patients were not counted as withdrawals in the study data.

(14)

3Patients randomised into 3 groups (EVR + reduced TAC, TAC elimination and TAC control). Recruitment to the TAC elimination group was stopped 120-180 days after randomisation due to a significantly higher rate of rejection in this arm. We report outcomes for the TAC elimination and TAC control arms.

4One patient from the sirolimus arm was not included in the ITT population (n=148) because they did not receive the mTORi intervention. It has been assumed that this patient was not counted as a withdrawal in the study data.

CNI, calcineurin inhibitor; mTORi, mammalian target of rapamycin inhibitor; TAC, tacrolimus; ITT, intention to treat

References

1. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928.

2. De Simone P, Metselaar HJ, Fischer L, et al. Conversion from a calcineurin inhibitor to everolimus therapy in maintenance liver transplant recipients:

a prospective, randomized, multicenter trial. Liver Transpl 2009;15:1262-1269.

3. Masetti M, Montalti R, Rompianesi G, et al. Early withdrawal of calcineurin inhibitors and everolimus monotherapy in de novo liver transplant recipients preserves renal function. Am J Transplant 2010;10:2252-2262.

a meta-analysis of randomised

Conversion from calcineurin to mammalian target of rapamycin inhibitors in liver transplantation: a meta-analysis of randomised controlled trials

Thomas E Glover, Christopher JE Watson, Paul Gibbs, J Andrew Bradley, Evangelia E Ntzani, Vasilis Kosmoliaptsis

Supplementary Information Data extraction

Data extraction was performed independently by 2 investigators (TG and EEN) and discrepancies were resolved by a third investigator (VK).

rejection, graft loss, patient survival and adverse events. All outcomes were analysed at one year post-randomisation; longer term outcomes, if

available, were analysed for the latest time-point.

Assessment of methodological quality

The methodological quality of included trials and the risk of bias were assessed by using elements included in the Cochrane Collaboration’s tool for assessing risk of bias (1). The domains used in the present systematic review pertained to randomisation and allocation concealment

(selection bias), blinding (performance and detection bias), loss to follow-up and adherence to the intention-to-treat principle (attrition bias). We chose to present the meta-analysis of all studies while providing a summary of the risk of bias across studies.

Data synthesis and statistical analysis

For each trial we retrieved or calculated the crude risk ratio (RR) estimates and corresponding 95% confidence intervals (CI) for the assessed

binary outcomes (acute rejection, graft loss, patient survival and adverse events), and the mean difference (MD) and corresponding standard

deviation (SD) for the assessed continuous outcomes (GFR). We also used the standardised mean difference (and 95% CI), which expresses the

mean score difference in SD units, and can be used to directly compare different scales or scores across the individual studies. The presence of

statistically significant heterogeneity was assessed by the Q statistic (significant at p<0.10) and the extent of the observed heterogeneity was

assessed by the I

(ranging from 0% to 100%). The overall summary MD, SMD and RR effect sizes were estimated using both fixed and random

effects models. Analyses performed using these models yielded similar results. We chose to report summary estimates using random-effects

models because, in the presence of heterogeneity, they provide more conservative estimates. Summary effect estimates for renal function, acute

rejection, graft loss and patient survival were based on intention-to-treat (ITT) populations as reported in the study publications; moreover, all

eligible studies reported adverse events for the safety population and, therefore, summary effect sizes for adverse events were estimated based on safety populations as reported in the study publications.

) by multiplication of the SMD by the baseline standard deviation (of mean GFR) reported in the largest included trial by Abdelmalek et al (4).

Table S1. Literature search algorithm

[(calcineurin inhibitor OR cyclosporine OR ciclosporin* OR neoral* OR sandimmun* OR tacrolimus OR FK506 OR FK 506 OR prograf OR

advagraf OR adoport) AND (rapamycin derivative OR rapamune OR sirolimus OR mtor inhibitor or mTORC1 inhibitor OR TOR inhibitor OR

mammalian target of rapamycin OR rapamycin* OR everolimus OR RAD OR SDZRAD OR RAD001) AND (liver OR hepatic) AND (transplant OR transplantation OR graft OR graf OR transplant*)]

Table S2. Characteristics of included studies

Table S3: Risk of bias in the published controlled trials

Table S4: Characteristics of included studies reporting on acute rejection

Table S5. Patients that failed to be randomised and patients that discontinued the allocated treatment in included studies

References

1. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928.

2. De Simone P, Metselaar HJ, Fischer L, et al. Conversion from a calcineurin inhibitor to everolimus therapy in maintenance liver transplant recipients:

a prospective, randomized, multicenter trial. Liver Transpl 2009;15:1262-1269.

3. Masetti M, Montalti R, Rompianesi G, et al. Early withdrawal of calcineurin inhibitors and everolimus monotherapy in de novo liver transplant recipients preserves renal function. Am J Transplant 2010;10:2252-2262.

4. Abdelmalek MF, Humar A, Stickel F, et al. Sirolimus conversion regimen versus continued calcineurin inhibitors in liver allograft recipients: a

randomized trial. Am J Transplant 2012;12:694-705.

a meta-analysis of randomised

Conversion from calcineurin to mammalian target of rapamycin inhibitors in liver transplantation: a meta-analysis of randomised controlled trials

Thomas E Glover, Christopher JE Watson, Paul Gibbs, J Andrew Bradley, Evangelia E Ntzani, Vasilis Kosmoliaptsis

Supplementary Information Data extraction

Data extraction was performed independently by 2 investigators (TG and EEN) and discrepancies were resolved by a third investigator (VK).

rejection, graft loss, patient survival and adverse events. All outcomes were analysed at one year post-randomisation; longer term outcomes, if

available, were analysed for the latest time-point.

Assessment of methodological quality

The methodological quality of included trials and the risk of bias were assessed by using elements included in the Cochrane Collaboration’s tool for assessing risk of bias (1). The domains used in the present systematic review pertained to randomisation and allocation concealment

(selection bias), blinding (performance and detection bias), loss to follow-up and adherence to the intention-to-treat principle (attrition bias). We chose to present the meta-analysis of all studies while providing a summary of the risk of bias across studies.

Data synthesis and statistical analysis

For each trial we retrieved or calculated the crude risk ratio (RR) estimates and corresponding 95% confidence intervals (CI) for the assessed

binary outcomes (acute rejection, graft loss, patient survival and adverse events), and the mean difference (MD) and corresponding standard

deviation (SD) for the assessed continuous outcomes (GFR). We also used the standardised mean difference (and 95% CI), which expresses the

mean score difference in SD units, and can be used to directly compare different scales or scores across the individual studies. The presence of

statistically significant heterogeneity was assessed by the Q statistic (significant at p<0.10) and the extent of the observed heterogeneity was

assessed by the I

(ranging from 0% to 100%). The overall summary MD, SMD and RR effect sizes were estimated using both fixed and random

effects models. Analyses performed using these models yielded similar results. We chose to report summary estimates using random-effects

models because, in the presence of heterogeneity, they provide more conservative estimates. Summary effect estimates for renal function, acute

rejection, graft loss and patient survival were based on intention-to-treat (ITT) populations as reported in the study publications; moreover, all

eligible studies reported adverse events for the safety population and, therefore, summary effect sizes for adverse events were estimated based on safety populations as reported in the study publications.

) by multiplication of the SMD by the baseline standard deviation (of mean GFR) reported in the largest included trial by Abdelmalek et al (4).

Table S1. Literature search algorithm

[(calcineurin inhibitor OR cyclosporine OR ciclosporin* OR neoral* OR sandimmun* OR tacrolimus OR FK506 OR FK 506 OR prograf OR

advagraf OR adoport) AND (rapamycin derivative OR rapamune OR sirolimus OR mtor inhibitor or mTORC1 inhibitor OR TOR inhibitor OR

mammalian target of rapamycin OR rapamycin* OR everolimus OR RAD OR SDZRAD OR RAD001) AND (liver OR hepatic*) AND (transplant OR transplantation OR graft OR graf* OR transplant*)]

Table S2. Characteristics of included studies

Table S3: Risk of bias in the published controlled trials

Table S4: Characteristics of included studies reporting on acute rejection

Table S5. Patients that failed to be randomised and patients that discontinued the allocated treatment in included studies

References

1. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928.

2. De Simone P, Metselaar HJ, Fischer L, et al. Conversion from a calcineurin inhibitor to everolimus therapy in maintenance liver transplant recipients:

a prospective, randomized, multicenter trial. Liver Transpl 2009;15:1262-1269.

3. Masetti M, Montalti R, Rompianesi G, et al. Early withdrawal of calcineurin inhibitors and everolimus monotherapy in de novo liver transplant recipients preserves renal function. Am J Transplant 2010;10:2252-2262.

4. Abdelmalek MF, Humar A, Stickel F, et al. Sirolimus conversion regimen versus continued calcineurin inhibitors in liver allograft recipients: a

randomized trial. Am J Transplant 2012;12:694-705.

mammalian target of rapamycin OR rapamycin* OR everolimus OR RAD OR SDZRAD OR RAD001) AND (liver OR hepatic) AND (transplant OR transplantation OR graft OR graf OR transplant*)]