A Joint Pharmacokinetic Model for the Simultaneous Description of Plasma and Whole Blood Tacrolimus Concentrations in Kidney and Lung Transplant Recipients

Background and Objective Historically, dosing of tacrolimus is guided by therapeutic drug monitoring (TDM) of the whole blood concentration, which is strongly influenced by haematocrit. The therapeutic and adverse effects are however expected to be driven by the unbound exposure, which could be better represented by measuring plasma concentrations. Objective We aimed to establish plasma concentration ranges reflecting whole blood concentrations within currently used target ranges. Methods Plasma and whole blood tacrolimus concentrations were determined in samples of transplant recipients included in the TransplantLines Biobank and Cohort Study. Targeted whole blood trough concentrations are 4–6 ng/mL and 7–10 ng/mL for kidney and lung transplant recipients, respectively. A population pharmacokinetic model was developed using non-linear mixed-effects modelling. Simulations were performed to infer plasma concentration ranges corresponding to whole blood target ranges. Results Plasma ( n = 1973) and whole blood ( n = 1961) tacrolimus concentrations were determined in 1060 transplant recipients. A one-compartment model with fixed first-order absorption and estimated first-order elimination characterised observed plasma concentrations. Plasma was linked to whole blood using a saturable binding equation (maximum binding 35.7 ng/mL, 95% confidence interval (CI) 31.0–40.4 ng/mL; dissociation constant 0.24 ng/mL, 95% CI 0.19–0.29 ng/mL). Model simulations indicate that patients within the whole blood target range are expected to have plasma concentrations (95% prediction interval) of 0.06–0.26 ng/mL and 0.10–0.93 ng/mL for kidney and lung transplant recipients, respectively. Conclusion Whole blood tacrolimus target ranges, currently used to guide TDM, were translated to plasma concentration ranges of 0.06–0.26 ng/mL and 0.10–0.93 ng/mL for kidney and lung transplant recipients, respectively.