Transplant immunosuppression and drug interactions
The standard kidney transplant regimen (induction, then tacrolimus, mycophenolate and prednisolone), how to read a tacrolimus trough step by step, the interactions that cause toxicity or rejection, and pregnancy and vaccine rules for recipients.
Tier 2Medical sciences concept
Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- Kidney transplant immunosuppression has two phases: induction around the operation and lifelong maintenance. Rejection risk is highest in the first 3 to 6 months, so drug exposure is highest then and is lowered over the first year.
- The Australian default is tacrolimus + mycophenolate + prednisolone. KDIGO 2009 (still the current KDIGO recipient guideline in November 2026) and the 2012 KHA-CARI adaptation recommend this combination.
- Tacrolimus has a narrow therapeutic index and is a CYP3A4 and P-glycoprotein substrate. Most exam stems are a trough level plus a creatinine. Read the level, then ask whether the sample was a true trough, whether something changed, and whether the graft is the problem.
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Sources
- KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients. Am J Transplant 2009;9 Suppl 3:S1-155Kidney Disease Improving Global Outcomes, 2009 (still the current KDIGO version; no update published, checked November 2026)
- KHA-CARI adaptation of the KDIGO Clinical Practice Guideline for the Care of Kidney Transplant RecipientsAU/NZKHA-CARI, 2012 (current KHA-CARI transplant guideline, checked November 2026)
- Brunet M et al. Therapeutic drug monitoring of tacrolimus-personalized therapy: second consensus report. Ther Drug Monit 2019;41(3):261-307International Association of Therapeutic Drug Monitoring and Clinical Toxicology, 2019
- Ekberg H et al. Reduced exposure to calcineurin inhibitors in renal transplantation (ELITE-Symphony). N Engl J Med 2007;357:2562-75New England Journal of Medicine, 2007
- Pascual J et al. Everolimus with reduced calcineurin inhibitor exposure in renal transplantation (TRANSFORM). J Am Soc Nephrol 2018;29:1979-91Journal of the American Society of Nephrology, 2018
- Vincenti F et al. Belatacept and long-term outcomes in kidney transplantation (BENEFIT). N Engl J Med 2016;374:333-43New England Journal of Medicine, 2016
- Kotton CN et al. The Fourth International Consensus Guidelines on the Management of Cytomegalovirus in Solid Organ Transplantation. Transplantation 2025;109(7):1066-110The Transplantation Society, 2025
- Prescribing medicines in pregnancy databaseAU/NZTherapeutic Goods Administration
- Australian Medicines HandbookAU/NZAustralian Medicines Handbook Pty Ltd
- Australian Immunisation Handbook (Vaccination for people who are immunocompromised)AU/NZAustralian Government Department of Health, Disability and Ageing
- Last updated
- 14 November 2026
What changed
- 14 November 2026 Turnstile bot check on sign-in and signed-out feedback