# 一名腎臟移植個案正在使用 tacrolimus，通報谷濃度突然升高。護理師回顧近期變化。哪一項個案行為最可能造成濃度升高？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=391872&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一名腎臟移植個案正在使用 tacrolimus，通報谷濃度突然升高。護理師回顧近期變化。哪一項個案行為最可能造成濃度升高？

## 選項

1. 每天喝8杯水
2. 食用綠葉蔬菜
3. 每天步行30分鐘
4. 開始喝葡萄柚汁並使用clarithromycin；兩者都會抑制CYP3A4，使tacrolimus濃度升高並增加腎毒性風險 **✔ 正確答案**

**正確答案: 4**

## 解析

正確（2）：Tacrolimus 經由CYP3A4代謝；強效抑制因子（葡萄柚汁、clarithromycin、azole抗黴菌藥、diltiazem）會提高濃度，造成顫抖、AKI、高血壓、高血糖與神經毒性。應避免葡萄柚；任何新藥都需與移植團隊協調。目標谷濃度依移植後時間而異（例如5-15 ng/mL）。（1,3,4）無關。

## 深入解析

記憶提示 Calcineurin抑制劑（tacrolimus、cyclosporine）=「CYP3A4 + 腎毒性 + 神經毒性 + 糖尿病」。避免葡萄柚。聖約翰草會誘導代謝，增加排斥風險。

## 臨床情境

情境 45歲男性，腎臟移植後6個月，使用他克莫司 tacrolimus；谷濃度由7升至16 ng/mL，並出現新的顫抖與肌酐上升。飲食回顧發現他開始喝葡萄柚汁，且被開立clarithromycin。

## 重要概念

- **Calcineurin抑制劑** — 包括tacrolimus、cyclosporine；是移植後免疫抑制的核心藥物。
- **CYP3A4交互作用** — 抑制劑（葡萄柚、azole類、macrolide類、diltiazem）會使tacrolimus濃度上升；誘導劑（rifampin、聖約翰草、phenytoin）會使濃度下降。
- **Tacrolimus毒性** — 腎毒性、顫抖、高血壓、高血糖、神經毒性、牙齦肥厚。

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