Mistaken Administration of Hydroxyurea Instead of Tacrolimus in a Pediatric Kidney Transplant Recipient: A Case Report.

ABSTRACT: Tacrolimus is a core medication of anti-rejection regimens for pediatric kidney transplant recipients. It is well known to have a narrow therapeutic window, affected by multiple factors, including absorption differences that influence drug concentrations in the body. Genetic polymorphisms of metabolizing enzymes, drug interactions, and intercurrent illnesses can impact drug clearance. This case report discusses a unique situation where a 12-year-old kidney transplant recipient experienced undetectable concentrations of tacrolimus in whole blood that were initially thought to result from excessive clearance due to severe diarrhea. Our nurse case manager investigated potential pharmacy errors by recommending that we test the home medication bottle, which revealed the absence of tacrolimus. I

SUBMITTER: Lafond S 

PROVIDER: S-EPMC12710481 | biostudies-literature | 2025 Dec

REPOSITORIES: biostudies-literature