Table 1. The Alfred Hospital’s current LTx ‘Induction and initiation of Immunosuppression’ protocol (1,2).

Induction

❖ Tacrolimus: 5 mg orally if weight >50 kg, and 3 mg po if weight <50 kg

Tacrolimus should not be given to patients on bosentan, azoles, orkambi or age >55 with borderline renal function

❖ Azathioprine: 2 mg/kg orally on acceptance of organs

Mycophenolate mofetil 500 mg–1·gm may be preferred in select patients (i.e., those who are (sensitized or have low TPMT level i.e., <0.50) as discussed with transplant physician

Intra-operative

❖ Methylprednisolone 500 mg intravenously on reperfusion of each lung

Early post-operative

❖ Methylprednisolone:

• 75 mg (50 mg if weight <50 kg) intravenously every 8 hours for three doses followed by

• 1 mg/kg at 10.00 am daily, weaning by 5–10 mg every day until 20 mg/day (Intravenous or oral as tolerated)

❖ Tacrolimus:

• Aim to commence within 12 hours of arrival in ICU (assuming adequate urine output and renal function). Initial dose should be delayed or lowered in patients:

Taking bosentan, azoles or orkambi

Renal impairment

• Day 0–1: >50 kg 0.5 mg intravenously twice daily; (<50 kg 0.3 mg) as a 4-hour infusion

• Day 2–4: Convert to oral administration; 10:1 conversion (i.e., 0.5 mg IV tacrolimus is equivalent to 5 mg oral tacrolimus)

• Daily through levels and adjust, targeting a trough level of 10–12 mcg/L

❖ Azathioprine:

• 1.5 mg/kg/day intravenously or orally daily

• If TPMT activity <0.5 then consider mycophenolate

• Sensitized patients to commence mycophenolate mofetil with target dose 1gm twice daily if >50 kg; 15 mg/kg if <50 kg

❖ Basiliximab:

• 20 mg given intravenously days 0 and 4 in selected patients

Indications for use:

Baseline renal impairment

Complicated surgical procedure, shock state or poor urine output in ICU where renal injury is anticipated

Pediatric patients (dose of 10 mg to be used where <35 kg)

LTx, lung transplantation.