Drug monitoring and target levels for maintenance immunosuppression in adult kidney transplant recipients

Drug	Drug monitoring^*	Target level^¶
Tacrolimus	Immediate-release tacrolimus: whole-blood 12-hour trough (C0) levels Extended-release tacrolimus: whole-blood 24-hour trough (C0) levels	Target C0 levels: In patients who receive antilymphocyte-depleting agents (eg, rabbit antithymocyte globulin [rATG]-Thymoglobulin) for induction therapy: 7 to 10 ng/mL for the first month after transplantation 3 to 7 ng/mL for subsequent months In patients who do not receive antilymphocyte-depleting agents for induction therapy: 8 to 10 ng/mL for months 1 to 3 after transplantation 3 to 7 ng/mL for subsequent months
Cyclosporine	Whole-blood 12-hour trough (C0) levels or two-hour postdose (C2) levels^Δ	Target C0 levels: 200 to 300 ng/mL in months 1 to 3 after transplantation 50 to 150 ng/mL for subsequent months Target C2 levels: 800 to 1000 ng/mL in months 1 to 3 after transplantation 400 to 600 ng/mL for subsequent months
Sirolimus	Whole-blood trough levels, drawn one hour prior to the next oral dose	4 to 6 ng/mL
Everolimus	Whole-blood trough levels, drawn one hour prior to the next oral dose	5 to 7 ng/mL

* The frequency of drug monitoring varies depending upon the time posttransplant and transplant center protocol.

¶ Target levels may vary from center to center.

Δ Although monitoring of trough levels (12 hours postdose) of cyclosporine is common practice, there is a poor correlation between clinical outcome and drug exposure as assessed using this strategy. Thus, in some patients (eg, patients suspected of having poor cyclosporine absorption), 2-hour postdose cyclosporine levels are monitored. Among kidney transplant recipients, the C2 level may correlate more closely with exposure, with higher C2 concentrations being associated with decreased acute rejection rates in the first year posttransplant. However, C2 monitoring is often more difficult and less convenient for the patient.

Graphic 143738 Version 1.0

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Drug monitoring and target levels for maintenance immunosuppression in adult kidney transplant recipients