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Background Approximately 40% of pancreatic tumors smaller than 2 cm are missed at abdominal CT. Purpose To develop and to validate a deep learning (DL)-based tool able to detect pancreatic cancer at CT. Materials and Methods Retrospectively collected contrast-enhanced CT studies in patients diagnosed with pancreatic cancer between January 2006 and July 2018 were compared with CT studies of individuals with a normal pancreas (control group) obtained between January 2004 and December 2019. An end-to-end tool comprising a segmentation convolutional neural network (CNN) and a classifier ensembling five CNNs was developed and validated in the internal test set and a nationwide real-world validation set. The sensitivities of the computer-aided detection (CAD) tool and radiologist interpretation were compared using the McNemar test. Results A total of 546 patients with pancreatic cancer (mean age, 65 years ± 12 [SD], 297 men) and 733 control subjects were randomly divided into training, validation, and test sets. In the internal test set, the DL tool achieved 89.9% (98 of 109; 95% CI: 82.7, 94.9) sensitivity and 95.9% (141 of 147; 95% CI: 91.3, 98.5) specificity (area under the receiver operating characteristic curve [AUC], 0.96; 95% CI: 0.94, 0.99), without a significant difference (

This paper provides an introduction to laboratory databases established by Taiwan National Health Insurance Administration (NHIA) since 2015 and released for research since June 2017. The National Health Insurance (NHI) is a government-run single-payer program introduced in 1995 that now covers more than 99% of 23 million Taiwanese citizens. To prevent duplication of medication prescriptions and laboratory test and examination prescriptions, contracted health care providers are required to upload the results of laboratory tests and reports of examinations to the NHIA. The cumulative number of laboratory test results was 5.64 billion from January 2015 to the end of August 2020 for 602 types of test. There are 35 variables for each laboratory test result stored in the databases that can be used for research. However, different hospitals might use different format in reporting the results. The researchers therefore have to develop algorithms to include and exclude incompatible records and to determine whether the results are positive or negative (normal or abnormal). The NHIA suggests that researchers release their source codes of algorithms so that other researchers can modify the codes to improve inter-study comparability. Through the unique personal identification number, the laboratory data can be linked to NHI inpatient and outpatient claims data for further value-added analyses. Non-Taiwanese researchers can collaborate with Taiwan researchers to access the NHI laboratory databases.

Medical technology is undergoing rapid transformations, and the classifications of medical devices have also expanded greatly; therefore, it is necessary to develop appropriate reimbursement policies and pricing mechanisms in a timely manner. This paper aims to introduce the reimbursement coverage and pricing rules for medical devices in Taiwan. In addition, this paper identifies and evaluates available health technology assessments (HTA) and literature on published websites concerning medical device decision-making processes and pricing systems in South Korea and Japan, which are near Taiwan and have similar reimbursement coverage processes. Reimbursement policy and pricing mechanisms are constantly being revised in Taiwan, Japan, and South Korea. Recently, all three countries attempted to establish new reimbursement coverage decision-making and pricing rules, adopting a differentiated approach based on the level of evidence required for the appropriated reimbursement in terms of a feasible evaluation mechanism for providing patients with more effective medical devices. This article is expected to contribute to providing references to new reimbursement coverage decision-making and pricing rules.

The National Health Insurance Administration (NHIA) began a pilot telemedicine program for people in remote areas after the Ministry of Health and Welfare expanded the eligibility for telemedicine. The impact of the COVID-19 pandemic on the healthcare system also accelerated the inclusion of telemedicine in the scheme. This chapter discusses how 5G facilitates telemedicine services; for example, the virtual National Health Insurance (NHI) card could bring comprehensive medical service to more settings, such as home-based medical care, by virtualizing the identification process.The NHI played a pivotal role in Taiwan’s battle against COVID-19. Besides providing travel history, occupation, contact history, and cluster to medical providers on the NHI MediCloud systems, the NHI virtual private network system was used to distribute medical masks through contracted pharmacies in the early stage of the pandemic. Moreover, the NHIA pulled in data, including vaccination history and polymerase chain reaction test results, from the NHI database to the NHI Express app so that the public can manage their health promptly. The last part of the chapter discusses Taiwan’s successful story of opening data to the private sectors to carry out the name-based medical mask distribution system.

With the sharply escalating medical expenses, the National Health Insurance Administration (NHIA) has implemented a number of programs to contain expenditure, deliver patient-centered health care, and meet the medical needs of the super-aged society that Taiwan will face in the future.Taiwan has followed the steps of many advanced countries to separate medicine and pharmacy to promote medication safety. In this chapter, we describe various obstacles and contingent approaches to implementing a policy that is quite against the social norm. The outcome was analyzed to evaluate the effect of this controversial policy. To connect long-term care seamlessly after hospital discharge, discharge planning and follow-up management fees are covered by the National Health Insurance (NHI). The NHIA has also endeavored to encourage two-way referrals in the tiered medical care structure since 2017, hoping to improve the efficiency of the overall healthcare system through the redistribution of workload and the continuity of health care. Therefore, in addition to increasing the reimbursement for hospitalization and emergency treatment, differences in co-payment for referral visits from different levels of hospitals were applied to encourage better healthcare-seeking behavior. We also discuss the decision-making process of the on-going co-payment adjustment at the end of the chapter.

This chapter explains why National Health Insurance Administration (NHIA) decoupled the premium payment and right to health care to safeguard the medical right of the financially disadvantaged. Furthermore, various programs have been carried out to improve the accessibility and comprehensiveness of medical care for residents of remote and offshore islands. The National Health Insurance (NHI) has also progressively covered orphan drugs to meet the medical needs of patients with rare diseases.In addition to eliminating geographic and economic health disparity, the NHIA strives to improve health literacy and knowledge of the health insurance system of the public. “My Health Bank” was launched to enable its users to query personal medical and health information in real time to encourage self-health management and enhance the safety and quality of medical care. The NHI was introduced to elementary school pupils to acquaint the younger generation with its concept and have a more profound influence.

This chapter provides an overview of Taiwan’s National Health Insurance (NHI) system. In 1995, major social insurance programmes, such as labour insurance, government employee health insurance and farmers’ insurance, were merged and enlarged to form the NHI to deliver universal health coverage. Since its inception, the payment system of the NHI is the fee-for-service method. Moreover, most of the health care is provided by private sectors, and there are no restrictions on patients seeking medical care. Owing to the high medical accessibility, the volume of outpatient services is high, and the National Health Insurance Administration (NHIA) has to develop various measures to maintain its financial stability. Several strategies have been implemented by the NHIA for health equity, and the NHI MediCloud system, the NHI card and ‘My Health Bank’ were provided to ensure patients’ safety and enhance healthcare quality.

The National Health Insurance (NHI) is compulsory and provides universal health coverage to all citizens of Taiwan and those who have had a registered domicile, as well as foreigners holding alien residence certificates in Taiwan for 6 months. The right of the insured to access medical care is protected, whether they suffer from illness, injury or require reproductive care. This chapter introduces the financial structure of the NHI, enrolment eligibility and how the premiums are calculated for different insured groups and their insured units. The collection of supplementary premiums, which correlate additional premium contribution with non-salary-based income, is also explained. To maintain the financial independence and liability system of the NHI, by law, the premium rate is reviewed annually. Hence, the actuarial calculation of the premium rate plays a crucial role.

The virtual National Health Insurance (NHI) card not only represents digitization but also enables contactless health care during the pandemic. Under the process of full-scale digitization, the National Health Insurance Administration (NHIA) continues to refine the health service delivery measures, especially in the field of home-based medical care and telemedicine.Under the personal data protection regulation, the NHI data are opened for academic research purposes. More than 6550 published journal articles have utilized the NHI data, and these articles are made searchable online to support health policy management and clinical research. The NHI medical images combined with the application of artificial intelligence (AI) are the cornerstones of Taiwan’s smart health care. Domestic research teams are eligible to use the NHI database to verify or build their AI models after their research proposals are approved by the Management Council of the AI Application of NHI Data. The NHIA also plans to use NHI big data to develop digital patient decision aids by establishing a two-way digital interaction model to address the concerns of the healthcare providers and the public. By comparing the secondary use of health data in different countries, Taiwan is seeking a balance between innovation and conservative policies and is creating an environment that ensures the well-being of the next generation.

Ji-An Liang,1,2,* Po-Chang Lee,3,* Chun-Ping Ku,3,* William Tzu-Liang Chen,2,3,* Chih-Yuan Chung,4 Yu-Cheng Kuo,1,2 Szu-Hsien Chou,5 Chia-Chin Li,6 Chun-Ru Chien1,2,6 1Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan; 2School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; 3Department of Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan; 4Department of Medical Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan; 5Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan; 6Department of Radiation Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan*These authors contributed equally to this workCorrespondence: Chun-Ru ChienSchool of Medicine, College of Medicine, China Medical University, No. 91 Hsueh-Shih Road, North District, Taichung, 40402, TaiwanTel +886-4-22052121-7450Fax +886-4-22052121-7460Email d16181@gmail.comPurpose: Image-guided radiotherapy (IGRT) is an advanced radiotherapy technique to improve the radiotherapy delivery. We aimed to compare the overall survival (OS) for localized breast cancer (LBC) patient treated with adjuvant conventional fractionated radiotherapy (CFRT) using IGRT vs those without IGRT via a population-based analysis.Patients and Methods: Eligible LBC patients diagnosed between 2011 and 2013 were identified via the Taiwan Cancer Registry. We used propensity score (PS) weighting to balance observable potential confounders between groups. The hazard ratio (HR) of death and other outcomes were compared between IGRT and non-IGRT. We also evaluated OS in various supplementary analyses.Results: Our primary analysis included 6490 patients in whom covariates were well balanced after PS weighing. The HR for death when IGRT was compared with non-IGRT was 1.02 (95% confidence interval 0.80– 1.31, P = 0.86). There were also no significant differences in the supplementary analyses.Conclusion: We found that OS of LBC patients treated with adjuvant CFRT was not statistically different between those treated with IGRT versus without IGRT. This was the first study in this regard to our knowledge but randomized controlled trials were needed to confirm our finding.Keywords: breast cancer, effectiveness, image-guided radiotherapy

Background Low infection and case-fatality rates have been thus far observed in Taiwan. One of the reasons for this major success is better use of big data analytics in efficient contact tracing and management and surveillance of those who require quarantine and isolation. Objective We present here a unique application of big data analytics among Taiwanese people who had contact with more than 3000 passengers that disembarked at Keelung harbor in Taiwan for a 1-day tour on January 31, 2020, 5 days before the outbreak of coronavirus disease (COVID-19) on the Diamond Princess cruise ship on February 5, 2020, after an index case was identified on January 20, 2020. Methods The smart contact tracing–based mobile sensor data, cross-validated by other big sensor surveillance data, were analyzed by the mobile geopositioning method and rapid analysis to identify 627,386 potential contact-persons. Information on self-monitoring and self-quarantine was provided via SMS, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests were offered for symptomatic contacts. National Health Insurance claims big data were linked, to follow-up on the outcome related to COVID-19 among those who were hospitalized due to pneumonia and advised to undergo screening for SARS-CoV-2. Results As of February 29, a total of 67 contacts who were tested by reverse transcription–polymerase chain reaction were all negative and no confirmed COVID-19 cases were found. Less cases of respiratory syndrome and pneumonia were found after the follow-up of the contact population compared with the general population until March 10, 2020. Conclusions Big data analytics with smart contact tracing, automated alert messaging for self-restriction, and follow-up of the outcome related to COVID-19 using health insurance data could curtail the resources required for conventional epidemiological contact tracing.

BACKGROUND Low infection and case-fatality rates have been thus far observed in Taiwan. One of the reasons for this major success is better use of big data analytics in efficient contact tracing and management and surveillance of those who require quarantine and isolation. OBJECTIVE We present here a unique application of big data analytics among Taiwanese people who had contact with more than 3000 passengers that disembarked at Keelung harbor in Taiwan for a 1-day tour on January 31, 2020, 5 days before the outbreak of coronavirus disease (COVID-19) on the Diamond Princess cruise ship on February 5, 2020, after an index case was identified on January 20, 2020. METHODS The smart contact tracing–based mobile sensor data, cross-validated by other big sensor surveillance data, were analyzed by the mobile geopositioning method and rapid analysis to identify 627,386 potential contact-persons. Information on self-monitoring and self-quarantine was provided via SMS, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests were offered for symptomatic contacts. National Health Insurance claims big data were linked, to follow-up on the outcome related to COVID-19 among those who were hospitalized due to pneumonia and advised to undergo screening for SARS-CoV-2. RESULTS As of February 29, a total of 67 contacts who were tested by reverse transcription–polymerase chain reaction were all negative and no confirmed COVID-19 cases were found. Less cases of respiratory syndrome and pneumonia were found after the follow-up of the contact population compared with the general population until March 10, 2020. CONCLUSIONS Big data analytics with smart contact tracing, automated alert messaging for self-restriction, and follow-up of the outcome related to COVID-19 using health insurance data could curtail the resources required for conventional epidemiological contact tracing.

Background Those taking proton pump inhibitors (PPIs) might have a higher risk of acute kidney injury. The long-term safety, especially the PPI-associated chronic kidney disease (CKD) is the subsequent concern. Objective This study explores the potential relationship between using PPIs and CKD in Taiwan. Methods Using a database collated by the Taiwan National Health Insurance programme, we conducted a population-based case-controlled study to identify 16 704 cases of patients aged 20 years or older with newly diagnosed CKD between 2000 and 2013. 16 704 controls were randomly selected and were matched by sex, age and comorbidities. 'Use' of PPIs was defined as when subjects had received at least a prescription for PPIs before the index date. 'Non-use' was defined as subjects who had never received a prescription for PPIs before the index date. The odds ratio (OR) for CKD associated with the use of PPIs was estimated by a logistic regression model. Results The OR for CKD was 1.41 for subjects using PPIs [95% confidence interval (CI) 1.34, 1.48] compared with subjects who had never used PPIs. Almost all major types of PPIs present a weak association with increased odds of CKD in cumulative duration and dosage regression analysis. The OR in relation to cumulative duration (per month) of PPIs use was 1.02 (95% CI 1.01, 1.02) and the OR in relation to cumulative dosage (per microgram) of PPIs use was 1.23 (95% CI 1.18, 1.28). Conclusions Using PPIs presented 1.4-fold higher odds of CKD in Taiwan health insurance claims data analysis.

Quality of life is an important indicator for evaluating therapeutic outcomes and mortality in patients with end-stage renal disease. Few studies have explored the impact of symptom distress and social support on quality of life in this population. A correlational study was designed to examine the influence of symptom distress, social support and demographic characteristics on quality of life in renal transplant recipients. A convenience sample of 113 renal transplant recipients was recruited from a medical center in Southern Taiwan. A structured questionnaire was used to collect data. This four-part tool included: Quality of Life Index--Kidney Transplant Version III, Physical Symptom Distress Scale, Social Support Scale, and demographic characteristics. Data were analyzed by descriptive and inferential statistics (SPSS 10.1 statistical package). Percentage, rank, mean and standard deviation, t-tests, chi-square, ANOVA, Pearson's correlation and multiple regression were computed. Results showed that renal transplant recipients had a moderate quality of life. Social support and symptom distress, age, employment status, and household income significantly explained 28.8% of the variance in quality of life. Findings suggest implications for interventional programming and research aimed toward improving quality of life, including individual and family-based approaches designed to enhance recipients' social support and address effective management of symptoms. Recruiting a transplant clinical nurse specialist to design and implement an intervention program also is recommended.

Julio Pascual,1 Titte R Srinivas,2 Steven Chadban,3 Franco Citterio,4 Federico Oppenheimer,5 Helio Tedesco,6 Mitchell L Henry,7 Christophe Legendre,8 Yoshihiko Watarai,9 Claudia Sommerer,10 Po-Chang Lee,11 J Mark Hexham,12 Gaohong Dong,12 Peter Bernhardt,13Flavio Vincenti14 1Nephrology Department, Hospital del Mar, Barcelona, Spain; 2Division of Nephrology, Medical University of South Carolina, Mt Pleasant, SC, USA; 3Department of Transplantation, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; 4Centro Trapianti d'Organo Istituto di Clinica Chirurgica, Università Cattolica del Sacro Cuore, Policlinico Universitario A Gemelli, Rome, Italy; 5Renal Transplant Unit, Hospital Clínic de Barcelona, Barcelona, Spain; 6Nephrology Division, Hospital do Rim, UNIFESP, São Paulo, Brazil; 7The Comprehensive Transplant Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA; 8Service de Transplantation Adultes, Université Paris Descartes and Hôpital Necker, Paris, France; 9Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya City, Aich, Japan; 10Medizinische Klinik, Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Germany; 11Medical College, National Cheng Kung University, Tainan City, Taiwan; 12Biometrics and Statistical Science, Novartis Pharmaceuticals, East Hanover, NJ, USA; 13Research and Development, Novartis Pharma AG, Basel, Switzerland; 14Kidney Transplant Service, University of California San Francisco, San Francisco, CA, USA Abstract: Two well defined, modifiable risk factors for kidney allograft failure are acute rejection and poor graft function at one year post-transplant. Regulatory bodies and expert panels in the USA and Europe have recognized that both acute rejection and one-year graft function should be assessed when evaluating immunosuppressive regimens. TRANSFORM (Clinicaltrials.gov NCT01950819) is one of the first trials to adopt this approach and the first that applies a novel combined clinically meaningful endpoint to take the first step towards changing the paradigm for immunosuppression in kidney transplant patients. Everolimus with reduced-exposure calcineurin inhibitor (CNI) therapy is a strategy designed to reduce the risk of chronic nephrotoxicity and other dose-dependent complications associated with CNI therapy. In TRANSFORM, de novo kidney transplant patients are randomized to everolimus with reduced-exposure CNI, or mycophenolic acid with standard-exposure CNI, both with induction therapy and maintenance steroids. The primary endpoint is a composite of treated biopsy-proven acute rejection or estimated glomerular filtration rate ,50 mL/min/1.73 m2 at month 12 post-transplant, which is expected to be sensitive both to the effects of acute and chronic allograft rejection and nephrotoxic side effects of immunosuppressive therapies. The construct of this endpoint allows the integration of a continuous outcome (graft function) with a logistic outcome (rejection). The trial uses a randomized, multicenter, open-label, two-arm design. After completion of a 2-year core study, patients enter a further 3-year prospective observational study. By capturing follow-up to 5 years, TRANSFORM will provide substantial data on the incidence of graft loss, graft dysfunction, cancer, cardiovascular events, and other patient-relevant outcomes. TRANSFORM will determine whether de novo CNI reduction with an everolimus-based regimen achieves short-term outcomes compared with standard CNI. As the largest clinical trial undertaken to date in kidney transplantation, recruiting more than 2,000 patients, and with extended follow-up to 5 years, TRANSFORM will provide critical data required to help maximize long-term outcomes. Keywords: mTOR inhibitor, calcineurin inhibitor, reduced exposure

The Galerkin integral method is applied to calculate the Nusselt number for laminar flow in elliptic ducts imposed by constant wall temperature at the boundaries. The value of CfRe are also computed for elliptic ducts with and without central circular core. The flluid is assumed to be hydrodynamically fully developed laminar, and Newtonian. The thermally fully developed temperature can be obtained when the local Nusselt number approaches asymptotically to constant value. A six-term solution provides accurate predictions for the value of NuT in elliptic duct having a larger aspect ratio b/a. However, for duct with a smaller aspect ratio, a larger number of basis functions must be used.

Although the operative mortality of pancreaticoduodenal resection has decreased recently, the operative morbidity resulting from a leaking pancreatic anastomosis remains high. We described our experience in 50 consecutive cases with a simple, secure end to side pancreaticojejunostomy. We used a paediatric nasogastric tube in the pancreatic remnant duct as a temporary external pancreatic drain. There were 29 men and 21 women ranging from 12 to 84 years with a median age of 61 years. Forty-two patients underwent a standard Whipple procedure and eight a pylorus preserving pancreaticoduodenectomy. Average operating time was 270 minutes with a range of 170 to 480 minutes. The pancreaticojejunostomy could be constructed in a mean of 8 minutes. Intraoperative blood loss ranged from 150 to 3500 mL with a mean of 910mL. Twenty-five patients (50 %) received no blood transfusion. The consistency of the pancreatic remnant was hard in 12 patients (24 %) and normal in 38 patients (76 %). The pancreatic duct was dilated (>4mm) in 15 patients (30 %). There was no operative mortality and only three (6.0 %) minor leaks from the pancreatic anastomosis which healed spontaneously. It was difficult to determine if the leaks were related to the consistency of the pancreatic remnant, the size of the pancreatic duct, the amount of intraoperative blood loss, operating time, sex of the patient or experience of the surgeon, as there were only three leaks. We concluded that our technique for pancreaticojejunal anastomosis following pancreaticoduodenectomy was safe and applicable to, standard Whipple or pylorus preserving pancreaticoduodenectomy, small or dilated pancreatic ducts, normal or fibrotic pancreas.

Kidney transplant recipients receiving calcineurin inhibitor-based immunosuppression incur increased long-term risks of cancer and kidney fibrosis. Switch to mammalian target of rapamycin (mTOR) inhibitors may reduce these risks. Steroid or Cyclosporin Removal After Transplant using Everolimus (SOCRATES), a 36-month, prospective, multinational, open-label, randomized controlled trial for de novo kidney transplant recipients, assessed whether everolimus switch could enable elimination of mycophenolate plus either steroids or CNI without compromising efficacy. Patients received cyclosporin, mycophenolate and steroids for the first 14 days then everolimus with mycophenolate and CNIwithdrawal (CNI-WD); everolimus with mycophenolate and steroid withdrawal (steroid-WD); or cyclosporin, mycophenolate and steroids (control). 126 patients were randomized. The steroid WD arm was terminated prematurely because of excess discontinuations. Mean eGFR at month 12 for CNI-WD versus control was 65.1 ml/min/1.73 m2 vs. 67.1 ml/min/1.73 m2 by ITT, which met predefined noninferiority criteria (P = 0.026). The CNI-WD group experienced a higher rate of BPAR(31% vs. control 13%, P = 0.048) and showed a trend towards higher composite treatment failure (BPAR, graft loss, death, loss to follow-up). The 12 month results from SOCRATES show noninferiority in eGFR, but a significant excess of acute rejection when everolimus was commenced at week 2 to enable a progressive withdrawal of mycophenolate and cyclosporin in kidney transplant recipients.

An increasing number of studies have demonstrated adverse graft survival in patients who have anti-HLA antibodies, whether preformed or developed posttransplantation. This retrospective study used Lambda antigen tray-mixed (LAT-M) screening and Luminex HLA class I and II specificity assay to re-examine the impact of pretransplantation HLA antibody on long-term graft survival. In this study, pretransplantation sera from 288 renal patients were tested using the enzyme-linked immunosorbent assay (ELISA) method, LAT-M. Among the 234 of the patients who did not have pretransplantation antibodies, 85% enjoyed 5-year functional graft survival, 76% 10-year functional graft survival, and 56% 15-year functional graft survival. The corresponding functional graft survival for the 54 patients who tested HLA antibody-positive was 65%, 53%, and 28%, respectively (P = .0021).

Dear Editor, In their recent large, retrospective, cross-sectional study with 7702 renal-transplant patients, Einollahi et al. showed that cyclosporine (CsA) absorption (CA) steadily increases over 3 years post transplant (1). They also indicated that despite the day-to-day and inter-individual variability in CA, the CsA levels are routinely monitored by measuring the predose blood trough level (C0) or the 2-h post-dose level (C2). Their approach was to use the C2/C0 ratio as a measure of CA because it takes into account both the elimination and absorption phases, which are required to identify high and low CsA absorbers (1). According to the convention, the therapeutic target ranges for C0 and C2 of CsA were higher during the first 3 months post-transplant. Although the CsA dose was gradually reduced thereafter, as evidenced by the decreases in C0 and C2, to avoid CsA nephrotoxicity, CA increased during the 3-year post-transplant period. This increase in CA had a significant correlation with allograft function. CA levels also correlated with lower recipient age, hypokalemia, hypernatremia, hypotriglyceridemia, anemia, higher creatinine concentration, and lower LDL levels (1). Literature suggests that increase in CA after renal transplantation is influenced by numerous factors modifying CsA pharmacokinetics, including food, concomitant medication, CsA nephropathy, and decrease in CYP3A4 and P-glycoprotein levels (1). Increased serum creatinine and triglyceride levels, and hypokalemia are also associated with increased CsA levels (1, 2). Einollahi et al., through statistical analysis, showed that many of these factors correlated with higher CA. However, an important noteworthy point is that this study included long-term transplant patients, and the changes in CsA dose at the 4 time points post transplant were associated with decreased C0 and C2 levels and increased CA over a 3-year period (1). This finding suggests that the observed increase in CA is perhaps CsA specific, and highlights the role of inter-individual variability in CsA absorption as an important factor that must be considered for preventing CsA overuse-induced nephrotoxicity. Further, CsA co-administration increases the levels of other immunosuppressants such as mycophenolic acid, showing formulation-based variations (3). Therefore, further studies are needed to clarify the effect of CA on concomitant medications. Chapman et al. discussed the causes of chronic allograft nephropathy (CAN) and concluded that late identification of CAN leading to graft loss is an indication that the intervening strategies tend to be “too little and far too late” (4). A review by Vanrenterghem suggested that an individualized regimen requires selection of an immunosuppressive protocol and monitoring of individual drug-related toxicity, risk factors, and donor organ characteristics (5). Regarding toxicity, C0 does not indicate the amount of absorption, whereas C2 lacks the trough level aspect. Therefore, in renal-transplant patients on CsA, the C2/C0 ratio is a better marker and evidence of increasing CA as it indicates a fold increase in CsA levels from trough levels. In keeping with the spirit of doing “a little more” in patient interest, monitoring the C2/C0 ratio can serve as a balanced and individualized intervention strategy, which can also be applied to other drugs with a narrow therapeutic index.