Immunosuppression for lung transplantation

Abstract

As a result of advances in surgical techniques, immunosuppressive therapy, and postoperative management, lung transplantation has become an established therapeutic option for individuals with a variety of end-stage lung diseases. The current 1-year actuarial survival rate following lung transplantation is approaching 80%. However, the 5- year actuarial survival rate has remained virtually unchanged at approximately 50% over the last 15 years due to the processes of acute and chronic lung allograft rejection (1). Clinicians still rely on a vast array of immunosuppressive agents to suppress the process of graft rejection, but find themselves limited by an inescapable therapeutic paradox. Insufficient immunosuppression results in graft loss due to rejection, while excess immunosuppression results in increased morbidity and mortality from opportunistic infections and malignancies. Indeed, graft rejection, infection, and malignancy are the three principal causes of mortality for the lung transplant recipient. One should also keep in mind that graft loss in a lung transplant recipient is usually a fatal event, since there is no practical means of long-term mechanical support, and since the prospects of re-transplantation are low, given the shortage of acceptable donor grafts. This chapter reviews the current state of immunosuppressive therapy for lung transplantation and suggests alternative paradigms for the management of future lung transplant recipients.

Figure 1

Adult lung transplantation Kaplan-Meier survival by era (redrawn from [1]).

Figure 2

Trends in maintenance immunosuppression prior to discharge for lung transplantation: a) calcineurin inhibitors and b) antimetabolites.

Figure 3

Percentage of lung transplant patients still on original discharge regimens at 1, 2 and 3 years post-transplant, for the four most common regimen in 2001.

Figure 4

Trends in induction immunosuppression for lung transplantation, 1995–2004.