Transplantation immunology: paradigm shift from systemic suppression to microenvironment remodeling and precision modulation

Organ transplantation remains the definitive therapy for end-stage organ failure, yet its long-term success is limited by allograft rejection. Conventional immunosuppressive regimens, while effective against acute rejection, are hampered by non-specific mechanisms that lead to serious complications such as infections and malignancies, posing a major barrier to long-term graft survival. Recent advances in high-dimensional technologies-including single-cell sequencing, epigenomics, and metabolomics-are driving a paradigm shift in transplant immunology from "broad suppression" toward "precision modulation." This review systematically delineates the hierarchical network and regulatory mechanisms of the alloimmune response, with a focus on four pioneering therapeutic strategies: engineered cellular therapies, targeted biologics, local microenvironment remodeling, and metabolic/epigenetic interventions. It further discusses the integration of novel biomarkers, high-dimensional technologies, and artificial intelligence to establish a precision medicine framework for personalized immune management. Finally, future directions and challenges-including xenotransplantation, spatial multi-omics, and immune aging-are explored, providing a conceptual and practical roadmap for the fundamental transition from systemic immunosuppression to precision modulation of the immune microenvironment.