# Review the kidney transplant tacrolimus monitoring trend.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=568338&lang=en  
> language: en  
> subject: Medication Administration  
> category: PPT

## Question

Review the kidney transplant tacrolimus monitoring trend.

| Time | Data |
| --- | --- |
| Day 1 | data: Tacrolimus trough 8 ng/mL, Creatinine 1.1 mg/dL, Urine output 1800 mL/24h, Potassium 4.2 mEq/L, No tremor, BP 128/78 |
| Day 3 | data: Tacrolimus trough 12 ng/mL, Creatinine 1.3 mg/dL, Urine output 1500 mL/24h, Potassium 4.6 mEq/L, Mild tremor, BP 134/82 |
| Day 5 | data: Tacrolimus trough 18 ng/mL, Creatinine 1.6 mg/dL, Urine output 1100 mL/24h, Potassium 5.1 mEq/L, Moderate tremor, BP 142/88 |
| Day 7 | data: Tacrolimus trough 24 ng/mL, Creatinine 2.0 mg/dL, Urine output 800 mL/24h, Potassium 5.6 mEq/L, Severe tremor, BP 150/94 |

Q1. Based on the trend, what is the most likely cause of the patient's worsening renal function?

Urinary tract infection
Acute rejection of the transplanted kidney
Tacrolimus nephrotoxicity
Dehydration from decreased oral intake

Q2. Which finding most strongly supports tacrolimus toxicity rather than acute rejection?

Rising serum creatinine
Decreased urine output
Tacrolimus trough above 20 ng/mL with tremor
Hyperkalemia

Q3. What is the priority nursing action at Day 7?

Administer the scheduled tacrolimus dose and reassess in 24 hours
Encourage oral fluids and monitor urine output
Administer sodium polystyrene sulfonate for hyperkalemia
Hold the next tacrolimus dose and notify the transplant provider

## Explanation

The trend shows a rising tacrolimus trough, worsening renal function, and new hyperkalemia, which indicate tacrolimus toxicity and acute kidney injury. The nurse must distinguish toxicity from rejection and act promptly to prevent further harm.

## In-depth explanation

Quick answer
The rising tacrolimus trough above the target range, along with worsening creatinine, oliguria, and hyperkalemia, points to tacrolimus nephrotoxicity. The priority is to notify the transplant provider before the next dose, as continued dosing could worsen kidney injury.

Why this is correct
Tacrolimus has a narrow therapeutic index. Trough levels above 20 ng/mL are associated with nephrotoxicity, neurotoxicity, and electrolyte disturbances. The patient's trend shows a steady rise in trough and creatinine, with new hyperkalemia and reduced urine output, which are classic signs of toxicity rather than rejection.

Clinical picture
In tacrolimus toxicity, the provider may reduce the dose, hold a dose, or switch to an alternative immunosuppressant. The nurse should not independently adjust the dose or stop monitoring. Hyperkalemia may require urgent treatment, but the first step is to notify the provider who can order appropriate interventions.

Memory hook
Tacrolimus trough target is typically 5-15 ng/mL in the early post-transplant period, but varies by protocol. Creatinine >1.3 mg/dL or a rise of >0.3 mg/dL from baseline suggests acute kidney injury. Potassium >5.0 mEq/L requires prompt attention.

NCLEX decision rule
For any suspected drug toxicity, the nurse must first notify the prescriber before making changes. Do not administer the next dose if the level is toxic unless ordered.

Why the alternatives are wrong
Maintaining the current dose is unsafe because the trough is already above target and renal function is worsening. Giving extra tacrolimus or encouraging grapefruit juice would further increase levels. Stopping all lab monitoring would delay detection of worsening toxicity.

Sources
1NCSBN 2026 NCLEX-RN Test Plan
2DailyMed Tacrolimus

## Clinical scenario

Clinical Practice Guide
For a kidney transplant recipient on tacrolimus, compare new findings with baseline status, ordered data, and expected complications before choosing the priority response.

Caution
Do not delay urgent stabilization or escalation when airway, breathing, circulation, neurologic status, or safety is worsening.

## Key concepts

- **Tacrolimus trough** — The lowest blood concentration of tacrolimus just before the next dose, used to guide dosing. Target range varies by transplant protocol and time since transplant.
- **Acute kidney injury** — A rapid decline in kidney function, indicated by rising creatinine and decreased urine output. Can be caused by drug toxicity, rejection, or other factors.
- **Hyperkalemia** — Elevated serum potassium above 5.0 mEq/L, which can cause cardiac arrhythmias and requires prompt evaluation.

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