Background: High intrapatient variability in tacrolimus trough levels (Tac IPV) is associated with poor allograft outcomes. Tac IPV was previously calculated using trough levels 6-12 months after kidney transplantation (KT). Data on the accuracy of Tac IPV calculation over a longer period, the association between high Tac IPV and donor-specific antibody (DSA) development after KT in Asian patients, and the role of IPV in patients receiving concomitant cytochrome P450 (CYP)3A4/5 inhibitors (CYPinh) are limited.Methods: A retrospective review of patients who underwent KT at our center in 2005-2015, and who received Tac with mycophenolate during the first 2 years after KT was performed. IPV was calculated using Tac levels adjusted by dosage. DSA was monitored annually after KT using a Luminex microbead assay.Results: In total, 236 patients were enrolled. CYPinh were prescribed to 189 patients (80.1%): 145 (61.4%), 31 (13.1%), and 13 (5.5%) received diltiazem, fluconazole, and ketoconazole, respectively. Mean IPV calculated from adjusted Tac levels for 6-12 months (IPV [6][7][8][9][10][11][12] ) and 6-24 months (IPV 6-24 ) after KT were 20.64% 6 11.68% and 23.53% 6 10.39%, respectively. Twentysix patients (11%) showed late rejection and/or DSA occurrence, and had significantly higher IPV 6-24 (29.42% 6 13.78%) than others (22.77% 6 9.64%; P = 0.02). There was no difference in IPV [6][7][8][9][10][11][12] (24.31% 6 14.98% versus 20.17% 6 10.90%; P = 0.18). IPV [6][7][8][9][10][11][12] and IPV [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24] were comparable in patients who did and did not receive CYPinh. When using mean IPV 6-24 as a cutoff, patients with higher IPV 6-24 had a higher probability of developing DSA and/or late rejection (P = 0.048).Conclusions: Tac IPV 6-24 was higher and more significantly associated with DSA development and/or late rejection than Tac IPV 6-12 , independent of Tac trough level. This is the first study to demonstrate the impact of high IPV on DSA development in Asian patients, and that Tac IPV is comparable between patients with and without CYPinh.