Adaptive Immunosuppression in Lung Transplant Recipients Applying Complementary Biomarkers: The Zurich Protocol

• Published in: Medicina (Kaunas, Lithuania) Vol. 59; no. 3; p. 488
• Main Authors: Schuurmans, Macé M, Raeber, Miro E, Roeder, Maurice, Hage, René
• Format: Journal Article
• Language: English
• Published: Switzerland MDPI AG 01.03.2023; MDPI
• Subjects: Antibodies; Biological markers; Biomarkers; Biopsy; Blood cell count; Bone marrow; Bronchoscopy; Drug dosages; eosinophils; Graft rejection; Graft Rejection - prevention & control; Health aspects; Humans; Immunosuppression; Immunosuppression Therapy - adverse effects; Immunosuppressive Agents - adverse effects; Infections; Lung; lung transplantation; Lung transplants; Lungs; Lymphocytes; Measurement; Methods; Patients; Physiological aspects; Prevention; Quality management; Risk factors; Steroids; Surveillance; therapeutic drug monitoring; Transplant Recipients; Transplantation; Viewpoint; Viral infections; Switzerland; eosinophils; immunosuppression; lung transplantation; lymphocytes; therapeutic drug monitoring
• ISSN: 1648-9144; 1010-660X; 1648-9144
• DOI: 10.3390/medicina59030488

Achieving adequate immunosuppression for lung transplant recipients in the first year after lung transplantation is a key challenge. Prophylaxis of allograft rejection must be balanced with the adverse events associated with immunosuppressive drugs, for example infection, renal failure, and diabetes. A triple immunosuppressive combination is standard, including a steroid, a calcineurin inhibitor, and an antiproliferative compound beginning with the highest levels of immunosuppression and a subsequent tapering of the dose, usually guided by therapeutic drug monitoring and considering clinical results, bronchoscopy sampling results, and additional biomarkers such as serum viral replication or donor-specific antibodies. Balancing the net immunosuppression level required to prevent rejection without overly increasing the risk of infection and other complications during the tapering phase is not well standardized and requires repeated assessments for dose-adjustments. In our adaptive immunosuppression approach, we additionally consider results from the white blood cell counts, in particular lymphocytes and eosinophils, as biomarkers for monitoring the level of immunosuppression and additionally use them as therapeutic targets to fine-tune the immunosuppressive strategy over time. The concept and its rationale are outlined, and areas of future research mentioned.