Immunosuppressive therapy for lung transplantation

Appropriate management of immunosuppressive therapy remains one of the major challenges after lung transplantation. Preoperative therapy consists of intravenous azathioprine and oral cyclosporin. Early postoperative therapy consists of standard triple immunosuppression with corticosteroids, azathioprine and either cyclosporin ortacrolimus. Previously, corticosteroids were withheld in the first postoperative week to allow for healing of the bronchial anastomosis. However, it has been demonstrated that corticosteroids can be safely begun immediately postoperatively and this is done in most centres. Recent clinical trials suggest that the use of tacrolimus instead of cyclosporin may result in fewer episodes of acute cellular rejection and improved graft survival. However, the majority of centres continue to use cyclosporin, as the use of tacrolimus requires special laboratory equipment and experience. However, more centres are likely to begin using tacrolimus if data continues to demonstrate improved graft survival. The use of antilymphocyte antibody preparations in the immediate postoperative period has been found to result in a high incidence of cytomegalovirus infection. Therefore, most centres restrict the use of antilymphocyte antibody preparations to episodes of recurrent acute cellular rejection or refractory chronic rejection. Late postoperative immunosuppression is with azathioprine 1.0 to 2.0 mg/kg, cyclosporin at a dosage to maintain whole blood concentrations of 250 to 350 Hg/L (immunofluorescence assay) and prednisone (usually 10 mg/day). Treatment of rejection episodes is with corticosteroids (e.g. intravenous methylprednisolone 1 g/day for 3 days), antilymphocyte antibody preparations or by switching to tacrolimus in patients maintained on cyclosporin. The use of aerosolised immunosuppressants both to prevent rejection and to decrease systemic toxicity, and the creation of stable chimaeras by simultaneous lung and bone marrow transplantation, are under investigation. Adis international hr-mred Ail rights reserved.