The predictive value of tacrolimus intrapatient variability and time in therapeutic range for renal transplant outcomes

Tacrolimus is key in renal transplantation. This study evaluated optimal intrapatient variability (IPV) and time in therapeutic range (TTR) thresholds and association with renal outcomes. This single-center study (1999–2018) had a mean follow-up of 3 years. All patients received tacrolimus-based immunosuppression, and excluded those switching from cyclosporin. Receiver operating characteristic curves evaluated IPV and TTR cutoff values for biopsy-proved acute rejection (BPAR). Cox regression, <i>Chi</i>-square, Mann–Whitney U, Kaplan–Meier, and log-rank tests were used for outcome analysis. The cohort included 463 patients (mean age 47.3 years; 44.1% female). Most received cadaveric grafts (66.4%) and ABO-compatible transplants (97.4%). Preexisting diabetes and hypertension were present in 14.7% and 63.7%, respectively. Mean tacrolimus trough level was 7.28 ± 1.92 ng/mL. Patients with IPV ≥25.6% had increased doubling of serum creatinine (DSCr) at 6–12 months (<i>p</i> = 0.007) and within 5 years (<i>p</i> &lt; 0.001), and higher BPAR within 1 year (<i>p</i> = 0.025). Similarly, TTR &lt;81.1% was associated with increased DSCr at 6–12 months (<i>p</i> = 0.015) and within 5 years (<i>p</i> = 0.009), and higher graft failure rates (<i>p</i> = 0.001). An IPV &lt;25.6% was also associated with a lower risk of DSCr within 5 years (HR 0.11; 95% CI, 0.03–0.50) and BPAR within one year (HR 0.59; 95% CI, 0.35–0.98), as shown in the Cox proportional hazards analysis. Kaplan–Meier analysis demonstrated significantly lower survival in patients with IPV ≥25.6% compared to IPV &lt;25.6% (<i>p</i> = 0.028), but no significant survival difference between TTR groups (<i>p</i> = 0.337). IPV and TTR are valuable for predicting renal transplant outcomes, with IPV demonstrating stronger predictive ability. Minimizing IPV through frequent monitoring and adherence support could enhance graft survival.