Induction and maintenance immunosuppression in lung transplantation

Abstract

Immunosuppression for lung transplant recipients is a critical part of post-transplant care, to prevent acute and chronic rejection. Treatment protocols consist of induction and maintenance immunotherapy. Induction agents provide an immediate state of immunosuppression following transplantation and over time, and their use has become more commonplace. Several agents are available for clinical use, including anti-thymocyte globulin, alemtuzumab, and basiliximab, the latter being most commonly employed. Each induction agent has unique side effects and caveats to their use, of which we must be aware. Maintenance immunosuppression is initiated following transplant but requires multiple doses prior to reaching therapeutic levels. A calcineurin inhibitor, an anti-metabolite, and a corticosteroid are traditionally used, most commonly tacrolimus, mycophenolate mofetil, and prednisone. Dosing regimens and goal trough levels vary and are tailored to a patient's clinical status and duration post-transplant. Future clinical studies may be able to assist in determining the optimal induction and maintenance immunosuppression regimens. In the interim, we use cohort and registry data to guide our therapies.

Keywords: Immunosuppression; Induction; Lung transplant.

Fig. 1

Site of action for induction and maintenance immunosuppressants. Red bars indicate the site of binding/pathway blockade caused by each immunosuppressant agent. Notably, most immunosuppression regimens address multiple pathways that inhibit T-cell function. Due to their multiple sites of action, ATG and corticosteroids are not represented in the figure. Created by Adobe Illustrator