BackgroundGraft rejection and chronic CNI toxicity remain obstacles to organ transplant success. Current formulations of tacrolimus, such as Prograf (R) and Advagraf (TM), exhibit limitations in terms of pharmacokinetics and tolerability, related in part to suboptimal bioavailability. As dosing non-compliance can result in graft rejection, the once daily formulation of tacrolimus, Advagraf (TM), was developed (vs 2x/day Prograf (R)). Benefits of Advagraf (TM) are counterbalanced by delayed achievement of therapeutic trough levels and need for up to 50% higher doses to maintain Prograf (R)-equivalent troughs. Envarsus (R) is also a prolonged-release once-daily tacrolimus formulation, developed using MeltDose (TM) drug-delivery technology to increase drug bioavailability; improved bioavailability results in low patient drug absorption variability and less pronounced peak-to-trough fluctuations. In phase III de novo kidney transplant studies, Envarsus (R) proved non-inferior to twice-daily tacrolimus; however, no phase IV studies show superiority of Envarsus (R) vs Advagraf (TM) in de novo liver transplant (LTx) recipients.MethodsThe EnGraft compares bioavailability and tests superiority of Envarsus (R) (test arm) versus Advagraf (TM) (comparator arm) in de novo LTx recipients. A total of 268 patients from 15 German transplant centres will be randomised 1:1 within 14 days post-LTx. The primary endpoint is dose-normalised trough level (C/D ratio) measured 12 weeks after randomisation. Secondary endpoints include the number of dose adjustments, time to reach first defined trough level and incidence of graft rejections. Additionally, clinical and laboratory parameters will be assessed over a 3-year period.DiscussionC/D ratio is an estimate for tacrolimus bioavailability. Improving bioavailability and increasing C/D ratio using Envarsus could reduce renal dysfunction and other tacrolimus-related toxicities; previous trials have shown that a higher C/D ratio (i.e. slower tacrolimus metabolism) is not only associated with improved renal function but also linked to reduced neurotoxic side effects. A higher C/D ratio could improve clinical outcomes for LTx recipients; EnGraft has begun, with one third of patients recruited by January 2022.