Oral administration of tacrolimus in the presence of jejunostomy after liver transplantation.

The feasibility of oral administration of tacrolimus in the presence of an intestinal stoma after liver transplantation (LTx) has not been adequately demonstrated. A 10-month-old girl underwent LTx with biliary reconstruction using a Roux-en Y loop. She developed intestinal perforation and underwent a jejunostomy at 40-50 cm distal to the jejunojejunostomy of the Roux-en Y loop on day 8 post-LTx. Tacrolimus was given twice daily via a nasogastric tube or orally; the initial dose of tacrolimus was 0.10 mg/kg/day. Until the time of intestinal perforation, the trough level of tacrolimus ranged from 13.0 to 19.6 ng/mL. The dose-normalized trough concentration (DNTC) of tacrolimus ranged from 130 to 196 ng.kg.day per mg.mL (control: 80-145 ng.kg.day per mg.mL). For a 2-week period when the patient was septic, the tacrolimus dose was reduced to 0.05 mg/kg/day, with a subsequent trough level of 3.6-5.1 ng/mL (DNTC: 72-102 ng.kg.day per mg.mL). After 3 weeks, the dose was increased to 0.175 mg/kg/day with the disappearance of infection; the trough level ranged from 8.5 to 9.7 ng/mL with a peak level of 26.3 ng/mL (DNTC: 48.5-55.4 ng.kg.day per mg.mL). After the initiation of oral feeding, the dose was slightly increased to 0.20 mg/kg/day with the trough level ranging from 8.1 to 9.8 ng/mL (DNTC: 40.5-49 ng.kg.day per mg.mL). After closure of the jejunostomy, the dose of tacrolimus was reduced to 0.075 mg/kg/day to maintain the same trough level (7.9-9.1 ng/mL) and the DNTC ranged from 105 to 121 ng.kg.day per mg.mL. In conclusion, oral administration of tacrolimus may achieve the therapeutic level, even in the presence of jejunostomy after LTx, although the bioavailability is decreased.