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INTRODUCTION One factor impacting tacrolimus interpatient variability is the presence of CYP3A5 polymorphisms. Low tacrolimus concentration-to-dose ratios (CDRs), or rapid metabolizers (RMs), have been associated with poor graft function outcomes and higher biopsy-proven acute rejection (BPAR) rates in a predominantly white population. Pretransplant CYP genotyping is not routinely conducted, and therefore only a small number of studies have assessed the use of tacrolimus CDRs as a surrogate for metabolism. We explored differences in outcomes between patients with low tacrolimus CDRs and high tacrolimus CDRs (i.e., nonrapid metabolizers [NRMs]) in a diverse patient population. OBJECTIVE To determine the relationship between tacrolimus CDRs and graft and patient outcomes in kidney transplant recipients at a large transplant center between 2006 and 2016. METHODS Inclusion criteria consisted of adult kidney transplant recipients who received rabbit antithymocyte globulin induction followed by a maintenance regimen of tacrolimus, mycophenolate, and prednisone. The primary end point was BPAR at 1 year. Secondary end points included graft survival, patient survival, and toxicities. Determination of clusters was conducted using the two-step cluster analysis with a defined two-cluster distribution. Kaplan-Meier survival curves were created using the log-rank test. RESULTS The NRM cluster consisted of 322 patients with a mean CDR of 2.91 ng/ml/mg. The RM cluster consisted of 932 patients with a mean CDR of 1.14 ng/ml/mg. The BPAR at 1 year posttransplant was 3.7% in the NRM cluster and 3.6% in the RM cluster (p=0.95). Death at 5 years was higher in the NRM group compared with the RM group for unknown reasons (p=0.03). Differences in the incidence of posttransplant toxicities were not statistically significant at any time point, except for increased rates of cutaneous cancer at 5 years and cardiovascular disease overall in the NRM group. CONCLUSION Tailoring tacrolimus therapy early posttransplant based on CDR is not supported by the findings in this study.

Introduction: Engaging student pharmacists as pharmacist extenders to facilitate medication education may represent a unique pathway for preventing medication safety issues and mitigating downstream consequences in the high-risk kidney transplant (KTX) population. The aim of this study was to describe the implementation and impact of a student pharmacist-led counseling initiative designed to promote patient and caregiver understanding of transplant medications.Methods: This is a single-center, retrospective quality improvement initiative comparing adult KTX recipients who received interventional student pharmacist-led education vs a historical cohort. Data on clinical outcomes, including the incidence of medication errors (MEs), adverse drug events (ADEs), and readmissions, was extracted from the patient's electronic medical record. In the intervention cohort, attendee satisfaction was assessed based on responses obtained from surveys distributed to patients and caregivers on the day they attended the student pharmacistled class.Results: A total of 311 KTX recipients were included in this analysis; 149 in the intervention cohort and 162 in the historical cohort. Patients in the intervention cohort experienced more MEs than those in the historical cohort (31 vs 11; P < .001). Rates of ADEs within the first 30 days post-transplant were comparable across cohorts (56 vs 52; P = .406). No significant difference in readmissions at days 7, 14, and 30 was observed between groups. Attendee satisfaction was high across all survey response fields. Conclusion:The results of this study demonstrate that KTX recipients who participated in student-pharmacist led medication counseling had comparable rates of ADEs and readmissions to those who did not, but were more likely to experience MEs. Future research is needed to explore the role of structured medication counseling and the utility of student pharmacists in the clinical setting.

Malignancy after solid organ transplant is a common occurrence that is associated with increased morbidity and mortality. Literature in the general diabetic population has identified possible antineoplastic properties of metformin. This retrospective study aims to determine if metformin results in a malignancy risk reduction in a cohort of diabetic kidney, liver, and heart transplant recipients. The population included transplant recipients without use of metformin at any time point (DMO arm, n = 147) and those with use of metformin (DMM arm, n = 172); the two arms were matched based on organ type and transplant date prior to application of exclusion criteria. Recipients with prior malignancy, malignancy before diabetes diagnosis, and metformin duration <30 days were excluded. The primary endpoint of malignancy first occurrence post‐transplant was not found to be statistically significant at 1, 5, 10, and 15 years. In the subgroup of heart transplant recipients, there was a significant reduction in malignancy at 15 years post‐transplant. Older age and Caucasian race were identified as significant risk factors for malignancy, while never smoker was a protective factor. Metformin use in this solid organ transplant cohort was not found to significantly reduce malignancy risk compared to use of other anti‐diabetic agents.

Background The influence of converting to once daily, extended‐release LCP‐Tacrolimus (Tac) for those with high tacrolimus variability in kidney transplant recipients (KTRs) is not well‐studied. Methods Single‐center, retrospective cohort study of adult KTRs converted from Tac immediate release to LCP‐Tac 1‐2 years post‐transplant. Primary measures were Tac variability, using the coefficient of variation (CV) and time in therapeutic range (TTR), as well as clinical outcomes (rejection, infections, graft loss, death). Results A total of 193 KTRs included with a follow‐up of 3.2 ± .7 years and 1.3 ± .3 years since LCP‐Tac conversion. Mean age was 52 ± 13 years; 70% were African American, 39% were female, 16% living donor and 12% donor after cardiac death (DCD). In the overall cohort, tac CV was 29.5% before conversion, which increased to 33.4% after LCP‐Tac (p = .008). In those with Tac CV >30% (n = 86), conversion to LCP‐Tac reduced variability (40.6% vs. 35.5%; p = .019) and for those with Tac CV >30% and nonadherence or med errors (n = 16), LCP‐Tac conversion substantially reduced Tac CV (43.4% vs. 29.9%; p = .026). TTR significantly improved for those with Tac CV >30% with (52.4% vs. 82.8%; p = .027) or without nonadherence or med errors (64.8% vs. 73.2%; p = .005). CMV, BK, and overall infections were significantly higher prior to LCP‐Tac conversion. In the overall cohort, 3% had rejection before conversion and 2% after (p = NS). At end of follow‐up, graft and patient survival were 94% and 96%, respectively. Conclusions In those with high Tac CV, conversion to LCP‐Tac is associated with a significant reduction in variability and improvement in TTR, particularly in those with nonadherence or medication errors.