Therapeutic drug monitoring

(Suggestions are based on Level III and IV evidence) • In both adults and children, C2 monitoring of CSA is superior to C0 as a predictor of AUC 0–4 and AUC 0–12. The C3 level is marginally superior to C2 for AUC 0–12. • Targeting AUC 0–4 levels for CSA of greater than 4400 ng/mL or C2 levels of greater than 1.5 by the end of the first week post transplant is associated with less acute rejection than targets lower than these levels. • In maintenance renal transplant recipients with C2 levels of >800 ng/mL, reduction to a level of 700–800 ng/mL allows CSA dose reduction without harm or proven benefit. • In children and adults, C0 (trough) levels of TAC correlate well with AUC0−12 h. Other time points (e.g. C2, C3 or C4 levels) are better correlated, especially with AUC0−4 h but as yet, there is no proven clinical advantage for routine transplants. • For both calcineurin inhibitors (CNIs), two or three point limited sampling strategies (LSS) increase the predictive value for AUC 0–4 and AUC 0–12 over any single time point strategy. • For both CNIs, two or three point sampling estimates of absorption profiles may be required in individuals with known variable absorption. This includes children, nonWhite races and those with concomitant disease such as liver dysfunction and diabetes.