Immunosuppression for lung transplant recipients

The choices and extent of immunosuppression critically affect subsequent infection and rejection profiles after lung transplantation (LTx). Evidence does not support a particular induction strategy. Typically, a three drug regimen of a calcineurin inhibitor, cell cycle inhibitor, and corticosteroids provide LTx maintenance immunosuppression. Other agents (including mTOR inhibitors), and other routes of administration (sublingual or inhaled) tend to be held back for specific clinical problems. Treatment of acute cellular rejection with high dose corticosteroids is usually successful. By contrast, treatment of antibody–mediated rejection is problematic. It requires a combination of high dose corticosteroids, plasmapheresis, rituximab, and intravenous immunoglobulin. Chronic lung rejection is a particular challenge to treat. It is generally stated that any change in immunosuppression can lead to an apparent stabilization. Azithromycin and statins have some efficacy when used early. The current review aims to highlight the rationale for current immunosuppressive choices and draw attention to recent trends and developments.