Immunosuppression

Most lung transplant programs use an immunosuppression protocol similar to that employed in their pediatric heart transplant program. Traditionally, a "triple drug" protocol based on steroids, azathioprine and cyclosporine is used.

Intravenous cyclosporine may be administered by continuous infusion to achieve a whole blood level of cyclosporine of 300-350 ng/ml in the early postoperative period. To achieve this blood level typically requires a cyclosporine dosage of 0.5-1.0 mg/hr, but the dosage must be determined empirically and adjustments determined by blood level. During the first 24-72 hours posttransplant, a cyclosporine level between 200 and 250 ng/ml is acceptable and will minimize the risk of early renal impairment. This is especially important since diuresis is vital in the early postoperative period. Azathioprine 2 mg/kg (i.v. or p.o.) is given daily and the dosage decreased or held if the white blood cell count falls below 5000. Methyl-prednisolone 1 mg/kg/day (i.v. or p.o.) in divided doses is started immediately posttransplant and slowly tapered (over weeks) to approximately 0.2 mg/kg/day.

Some lung transplant programs have employed immunosuppression protocols using tacrolimus and mycophenolate mofetil instead of cyclosporine and azathio-prine. One immunosuppression protocol has not been shown to be better than another, but tacrolimus may offer advantage in terms of ease of administration in children.

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