title: Future direction of immunosuppression in lung transplantation.
abstract: OBJECTIVE
  Immunosuppression regimens have helped improve rejection episodes following lung transplantation, but long-term outcomes are still not comparable with cardiac, hepatic, or renal transplantation. This review summarizes the immunobiology that contributes to rejection events and future opportunities in outcomes on the basis of providing optimized delivery of the immunosuppression based on immune-monitoring techniques, taking into account individual patient pharmacokinetics and phenotypic variance.
  
  
  RESULTS
  Drug toxicities, narrow therapeutic drug monitoring windows, and current immunoassays currently do not assist in detecting the global degree of immunosuppression. The currently available randomized control trials for induction therapy or maintenance therapies do not provide additional benefits compared with previously reported retrospective trials. To push beyond the current barriers, transplant teams are focusing on the role of pharmacokinetics, assessing phenotypic variable to potentially modify to quadruple therapy and using extracorporeal photopheresis.
  
  
  CONCLUSIONS
  Conventional practice for the choices of immunosuppression is being evaluated on the basis of randomized control trials as opposed to retrospective studies or single-center trials. The future direction of immunosuppression will be continued by dynamic processes taking into consideration measures to improve tolerance, reducing treatment burden, and providing the best level of evidence while accounting for rejection, infections, renal function, and other comorbidities.
authors.affiliation: aUSC Center for Advanced Lung Disease, Keck School of Medicine, University of Southern California bDivision of Pulmonary, Critical Care and Sleep Medicine, Los Angeles, California, USA.
authors.forename: Kamyar
authors.initials: K
authors.lastname: Afshar
mesh_terms: D000818:Animals; D002986:Clinical Trials as Topic; D006086:Graft vs Host Disease / Q000276:immunology; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D016040:Lung Transplantation / Q000009:adverse effects
chemical_list: D007166:Immunosuppressive Agents