Calcineurin-inhibitor refractory bronchiolitis obliterans (BO) represents
IntroductionIntroduction of calcineurin inhibitors (CNIs) has significantly reduced acute rejection rates and was anticipated to have implications for long-term prognosis (1). However, current data indicate that, contrary to expectations, long-term survival rates poorly reflect short-term improvements. Lung transplantation (LTx), which remains the only therapeutic approach for end-stage lung failure, is no exception. The 1-year survival rate for LTx is >80% whereas the 10-year survival rate does not exceed 23% (1). Bronchiolitis obliterans (BO) is the leading cause of late failure after lung transplantation. Although immune mechanisms including T cell-mediated alloreactivity and autoimmunity appear to be central to the pathology of BO, detailed mechanisms remain poorly understood. Recent reports in rodents and in humans suggest a role for the involvement of Th2 (2) and Th17 (3,4) in the pathogenesis of BO, although the latter may still be controversial (5). Whereas the large majority of lung transplant recipients receive CNI-based immunosuppressive regimens, more than 50% develop BO (6). This suggests that mechanisms underlying BO resist treatment by CNIs or could even be promoted by these drugs.