Precision immunosuppression in adult lung transplantation: are we there yet?

PURPOSE OF REVIEW: Long-term outcomes after adult lung transplantation remain limited by rejection, infection, and toxicity related to immunosuppressive therapy. Conventional protocol-based immunosuppression fails to account for substantial interindividual variability in immune risk, drug metabolism, and susceptibility to complications. This review is timely as emerging biomarkers and digital tools promise to shift lung transplantation toward individualized immune management. RECENT FINDINGS: Recent studies highlight the role of Torque Teno virus (TTV) load as a surrogate marker of net immunosuppression, donor-derived cell-free DNA (dd-cfDNA) as a sensitive indicator of graft injury, and tissue-bound donor-specific antibodies as markers of localized alloimmune activity. Pharmacogenomic profiling and immunomodulatory strategies such as extracorporeal photopheresis further enable risk-adapted therapy. Integration of blood and BAL-based biomarkers allows earlier detection of subclinical rejection and infection risk. SUMMARY: Precision immunosuppression in lung transplantation is transitioning from concept to early clinical implementation. Combining clinical risk stratification with immune and graft-injury biomarkers may allow safer immunosuppression minimization and improved long-term outcomes, although prospective validation is still required.