{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,30]],"date-time":"2025-12-30T20:18:13Z","timestamp":1767125893225,"version":"3.48.0"},"reference-count":44,"publisher":"The Pediatric Pharmacy Association","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:p>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. Instead, the patient was given hydroxyurea, an anti-metabolite commonly used for oncologic and hematologic indications and can cause diarrhea, thrombocytopenia, and neutropenia. The patient experienced borderline rejection. The cause of this pharmacy error was multifactorial. However, confusion and complexities in the compounding process of liquid formulations likely played a role. This report underscores the importance of considering pharmacy errors as a potential cause of variations in tacrolimus drug concentrations. It emphasizes the role of nurses and interdisciplinary collaboration in identifying and addressing medication errors. It also underscores the need for standardization in the pharmaceutical compounding process and advocates for pharmaceutical industries to produce pediatric-appropriate formulations to reduce such errors.<\/jats:p>","DOI":"10.5863\/jppt-24-00133","type":"journal-article","created":{"date-parts":[[2025,12,15]],"date-time":"2025-12-15T15:57:30Z","timestamp":1765814250000},"page":"812-816","source":"Crossref","is-referenced-by-count":0,"title":["Mistaken Administration of Hydroxyurea Instead of Tacrolimus in a Pediatric Kidney Transplant Recipient: A Case Report"],"prefix":"10.5863","volume":"30","author":[{"given":"Sarah","family":"Lafond","sequence":"first","affiliation":[{"name":"Children\u2019s Hospital (SL), London Health Sciences Centre, London, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alethia Paulina Monserrat Guzman","family":"Nu\u00f1ez","sequence":"additional","affiliation":[{"name":"Department of Paediatrics (APMGN), Hospital Infantil de M\u00e9xico Federico G\u00f3mez, Instituto Nacional de Salud, Mexico City, Mexico"},{"name":"Department of Pediatrics, East Jeddah Hospital, Jeddah, Saudi Arabia, 22253"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mashael","family":"Abujabal","sequence":"additional","affiliation":[{"name":"Department of Pharmacy (MA), Mount Sinai Hospital, Toronto, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emily","family":"Chen","sequence":"additional","affiliation":[{"name":"Departments of Paediatrics and Medicine (EC, GF), Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Guido","family":"Filler","sequence":"additional","affiliation":[{"name":"Departments of Paediatrics and Medicine (EC, GF), Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada"},{"name":"The Lilibeth Caberto Kidney Clinical Research Unit (GF), Western University, London, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"3883","reference":[{"issue":"3","key":"JPPT-24-00133-b01","series-title":"Pediatr Nephrol","first-page":"141","article-title":"Randomized trial of tracolimus versus cyclosporin microemulsion in renal transplantation","volume":"17","author":"Trompeter","year":"2002","unstructured":"Trompeter R, Filler G, Webb NJA, et al. Randomized trial of tracolimus versus cyclosporin microemulsion in renal transplantation. Pediatr Nephrol. 2002;17(3):141\u2013149. http:\/\/www.scopus.com\/inward\/record.url?eid=2-s2.0-0036943134&partnerID=40&md5=d30cd91fbb88b16f2589f8afa3fea94f."},{"issue":"4","key":"JPPT-24-00133-b02","series-title":"Pediatr Transplant","first-page":"498","article-title":"Four-year data after pediatric renal transplantation: a randomized trial of tacrolimus vs. cyclosporin microemulsion","volume":"9","author":"Filler","year":"2005","unstructured":"Filler G, Webb NJ, Milford DV, et al. Four-year data after pediatric renal transplantation: a randomized trial of tacrolimus vs. cyclosporin microemulsion. Pediatr Transplant. 2005;9(4):498\u2013503."},{"issue":"8","key":"JPPT-24-00133-b03","series-title":"Nephrol Dial Transplant","first-page":"1668","article-title":"Pharmacokinetics of tacrolimus (FK 506) in children and adolescents with renal transplants","volume":"12","author":"Filler","year":"1997","unstructured":"Filler G, Grygas R, Mai I, et al. Pharmacokinetics of tacrolimus (FK 506) in children and adolescents with renal transplants. Nephrol Dial Transplant. 1997;12(8):1668\u20131671."},{"issue":"8","key":"JPPT-24-00133-b04","series-title":"Clin Pharmacol Drug Dev","first-page":"899","article-title":"Differential effect of a continental breakfast on tacrolimus formulations with different release characteristics","volume":"10","author":"Huppertz","year":"2021","unstructured":"Huppertz A, Bollmann J, Behnisch R, et al. Differential effect of a continental breakfast on tacrolimus formulations with different release characteristics. Clin Pharmacol Drug Dev. 2021;10(8):899\u2013907."},{"issue":"4","key":"JPPT-24-00133-b05","series-title":"Am J Clin Exp Urol","first-page":"275","article-title":"A systematic review and meta-analysis recite the efficacy of tacrolimus treatment in renal transplant patients in association with genetic variants of CYP3A5 gene","volume":"11","author":"Chauhan","year":"2023","unstructured":"Chauhan PM, Hemani RJ, Solanki ND, et al. A systematic review and meta-analysis recite the efficacy of tacrolimus treatment in renal transplant patients in association with genetic variants of CYP3A5 gene. Am J Clin Exp Urol. 2023;11(4):275\u2013292."},{"issue":"3","key":"JPPT-24-00133-b06","series-title":"Pharmaceutics","first-page":"291","article-title":"Tacrolimus pharmacokinetic and pharmacogenomic differences between adults and pediatric solid organ transplant recipients","volume":"2","author":"Marfo","year":"2010","unstructured":"Marfo K, Altshuler J, Lu A. Tacrolimus pharmacokinetic and pharmacogenomic differences between adults and pediatric solid organ transplant recipients. Pharmaceutics. 2010;2(3):291\u2013299."},{"issue":"10","key":"JPPT-24-00133-b07","series-title":"Pharmaceutics","first-page":"2154","article-title":"Controversial interactions of tacrolimus with dietary supplements, herbs and food","volume":"14","author":"Miedziaszczyk","year":"2022","unstructured":"Miedziaszczyk M, Bajon A, Jakielska E, et al. Controversial interactions of tacrolimus with dietary supplements, herbs and food. Pharmaceutics. 2022;14(10):2154."},{"issue":"1","key":"JPPT-24-00133-b08","series-title":"Drug Metab Rev","first-page":"88","article-title":"Clinical determinants of calcineurin inhibitor disposition: a mechanistic review","volume":"48","author":"Vanhove","year":"2016","unstructured":"Vanhove T, Annaert P, Kuypers DR. Clinical determinants of calcineurin inhibitor disposition: a mechanistic review. Drug Metab Rev. 2016;48(1):88\u2013112."},{"issue":"6","key":"JPPT-24-00133-b09","series-title":"Am J Transplant","first-page":"1383","article-title":"Cytochrome P450 3A4 and P-glycoprotein activity and assimilation of tacrolimus in transplant patients with persistent diarrhea","volume":"5","author":"Lemahieu","year":"2005","unstructured":"Lemahieu W, Maes B, Verbeke K, et al. Cytochrome P450 3A4 and P-glycoprotein activity and assimilation of tacrolimus in transplant patients with persistent diarrhea. Am J Transplant. 2005;5(6):1383\u20131391."},{"issue":"7","key":"JPPT-24-00133-b10","series-title":"Transplant Proc","first-page":"2096","article-title":"Increased tacrolimus trough levels in association with severe diarrhea, a case report","volume":"36","author":"Asano","year":"2004","unstructured":"Asano T, Nishimoto K, Hayakawa M. Increased tacrolimus trough levels in association with severe diarrhea, a case report. 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Multifactorial causes of tacrolimus errors: confusion with strength\/formulation, look-alike names, preparation errors, and more ensuring safety of recipes for drug compounding please, no more teaspoon dosing. Hosp Pharm. 2018;53(3):142\u2013145."},{"issue":"5","key":"JPPT-24-00133-b12","series-title":"J Pediatr Hematol Oncol","first-page":"306","article-title":"Hydroxyurea therapy for pediatric patients with hemoglobin SC disease","volume":"23","author":"Miller","year":"2001","unstructured":"Miller MK, Zimmerman SA, Schultz WH, Ware RE. Hydroxyurea therapy for pediatric patients with hemoglobin SC disease. J Pediatr Hematol Oncol. 2001;23(5):306\u2013308."},{"issue":"5","key":"JPPT-24-00133-b13","series-title":"Blood","first-page":"1550","article-title":"Safety of hydroxyurea in children with sickle cell anemia: results of the HUG-KIDS study, a phase I\/II trial. 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Population pharmacokinetic analysis of tacrolimus in Mexican paediatric renal transplant patients: role of CYP3A5 genotype and formulation. Br J Clin Pharmacol. 2015;80(4):630\u2013641."},{"issue":"7","key":"JPPT-24-00133-b19","series-title":"Pediatr Nephrol","first-page":"1123","article-title":"Generic immunosuppressants","volume":"33","author":"Medeiros","year":"2018","unstructured":"Medeiros M, Lumini J, Stern N, et al. Generic immunosuppressants. Pediatr Nephrol. 2018;33(7):1123\u20131131."},{"issue":"3","key":"JPPT-24-00133-b20","series-title":"Br J Clin Pharmacol","first-page":"405","article-title":"Formulations for children: problems and solutions","volume":"79","author":"Batchelor","year":"2015","unstructured":"Batchelor HK, Marriott JF. Formulations for children: problems and solutions. Br J Clin Pharmacol. 2015;79(3):405\u2013418."},{"key":"JPPT-24-00133-b21","unstructured":"American Society of Health-System Pharmacists. Compound oral liquid standards. 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