title: Two case reports of successful withdrawal of mycofenolate mofetil after living donor lobar lung transplantation.
abstract: BACKGROUND
  Lung transplantation cases have immunosuppression maintained using a calcineurin inhibitor, anti-metabolites, and steroid.
  
  
  METHODS
  We report 2 clinical cases in which anti-metabolites (mycophenolate mofetil) were successfully withdrawn after living donor lobar lung transplantation by monitoring immune function using the ImmuKnow® assay. In the first case, a 43-year-old woman underwent living donor lobar lung transplantation for pulmonary alveolar proteinosis. Two healthy relatives donated a lower lobe each. Immunosuppression was maintained using tacrolimus, mycophenolate mofetil, and steroid. Six months posttransplantation, she developed invasive pulmonary aspergillosis. During anti-fungal treatment, we withdrew mycophenolate mofetil and tacrolimus trough levels were kept around 8 ng/mL. Despite the resulting low-level immunosuppression, the ImmuKnow assay showed immune function to be in the moderate range with tacrolimus and steroid alone, encouraging us to maintain this strategy to avoid recurrence of invasive pulmonary aspergillosis. In the second case, a 24-year-old man underwent living donor lobar lung transplantation for cystic fibrosis. Two healthy relatives donated a lower lobe each. Immunosuppression was maintained using tacrolimus, mycophenolate mofetil, and steroid. Five months posttransplantation, he developed persistent Pseudomonas aeruginosa pneumonia derived from the paranasal sinuses. Under ImmuKnow assay monitoring, mycophenolate mofetil was withdrawn, but immune function was maintained within the moderate range using tacrolimus and steroid alone.
  
  
  CONCLUSIONS
  Respiratory function in both cases was maintained; no findings of bronchiolitis obliterans syndrome were noted during this period. To the best of our knowledge, no reports have described successful anti-metabolite withdrawal in lung transplantation with ImmuKnow monitoring. Immune evaluation by ImmuKnow could offer a useful method to monitor and control immune status, particularly among recipients susceptible to infection, revealing that moderate immune function could be maintained using tacrolimus and steroid in living donor lobar lung transplantation.
authors: Division of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan. miyataku@nagasaki-u.ac.jp
authors: T
authors: T
authors: Miyazaki
authors: T
authors: T
authors: Tagawa
authors: N
authors: N
authors: Yamasaki
authors: T
authors: T
authors: Tsuchiya
authors: K
authors: K
authors: Matsumoto
authors: T
authors: T
authors: Nagayasu
mesh_terms: D000328:Adult; D003550:Cystic Fibrosis / Q000188:drug therapy / Q000276:immunology / Q000601:surgery; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D019520:Living Donors; D016040:Lung Transplantation / Q000379:methods*; D008297:Male; D009173:Mycophenolic Acid / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use; D011649:Pulmonary Alveolar Proteinosis / Q000276:immunology / Q000628:therapy*; D013256:Steroids / Q000627:therapeutic use; D016559:Tacrolimus / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D007166:Immunosuppressive Agents; D013256:Steroids; D009173:Mycophenolic Acid; D016559:Tacrolimus