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

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.

Inclusion Criteria: 1. Men\*\*, women\*, inter/diverse aged ≥ 18 or \ 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 \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)