A kidney transplant client on tacrolimus reports a sudden ri… | MyMerci
Medical Emergencies PA
Question

A kidney transplant client on tacrolimus reports a sudden rise in trough level. The nurse reviews recent changes. Which client behavior most likely caused the elevated level?

Explanation
Correct (2): Tacrolimus is metabolized by CYP3A4; potent inhibitors (grapefruit juice, clarithromycin, azole antifungals, diltiazem) raise levels, causing tremor, AKI, hypertension, hyperglycemia, neurotoxicity. Avoid grapefruit; coordinate any new drug with the transplant team. Target trough varies (e.g., 5-15 ng/mL depending on time post-transplant). (1,3,4) Unrelated.

In-depth explanation

Memory Tip Calcineurin inhibitor (tacrolimus·cyclosporine) = "CYP3A4 + Nephrotox + Neurotox + DM". Avoid grapefruit. St. John's wort INDUCES → rejection risk.

Clinical scenario

Scenario 45-year-old male 6 months post-kidney transplant on tacrolimus; trough rose from 7 to 16 ng/mL with new tremor and creatinine rise. Diet review: started grapefruit juice and was prescribed clarithromycin.

Key concepts

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For study reference only. Always follow current clinical guidelines and your institution’s protocols.