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Evaluation and treatment of acute lung transplant rejection

Joseph Pilewski, MD
Section Editor
Elbert P Trulock, MD
Deputy Editor
Helen Hollingsworth, MD


Acute allograft rejection is a significant problem in lung transplantation. Despite advances in induction immunosuppression and use of aggressive maintenance immunosuppression, more than a third of lung transplant recipients are treated for acute rejection in the first year after transplant [1-3]. Acute rejection is responsible for approximately 4 percent of deaths in the first 30 days following transplantation [2,3].

The clinical manifestations, evaluation, and treatment of acute cellular lung transplant rejection and the role of routine monitoring for rejection will be reviewed here. The immunobiology of transplantation, induction and maintenance immunosuppression after lung transplantation, humoral rejection, and chronic lung transplant rejection are discussed separately. (See "Transplantation immunobiology" and "Induction immunosuppression following lung transplantation" and "Maintenance immunosuppression following lung transplantation" and "Evaluation and treatment of antibody-mediated lung transplant rejection" and "Chronic lung transplant rejection: Bronchiolitis obliterans".)


Acute cellular rejection – Acute cellular rejection is the predominant type of acute lung transplant rejection and is mediated by T lymphocyte recognition of foreign major histocompatibility complexes (MHC), also known as human leukocyte antigens (HLA) in humans, or other antigens [1,4,5].

Humoral rejection – Humoral rejection, which is less common than acute cellular rejection, is mediated by antibodies directed against donor HLA or other epitopes. These antibodies may have been present in the recipient at a low level prior to transplant or may develop afterwards. Generally, if HLA antibodies are identified in the potential recipient, the corresponding HLA antigens are avoided in a donor (so-called virtual cross-match).

Hyperacute rejection is a form of humoral rejection that occurs in the first 24 hours following lung transplantation in recipients who have pre-formed anti-HLA antibodies. With improved sensitivity of HLA antibody testing, hyperacute rejection now rarely occurs.

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Literature review current through: Dec 2017. | This topic last updated: Dec 19, 2016.
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