Lung transplantation has emerged as the definitive treatment for end-stage pulmonary diseases including idiopathic pulmonary fibrosis (IPF), chronic obstructive pulmonary disease (COPD), pulmonary hypertension (PH), cystic fibrosis (CF), and non-CF bronchiectasis (particularly post-tuberculosis lung destruction in endemic regions like India). Despite significant advances, the median post-transplant survival remains limited to 6.7 years—the poorest among solid organ transplants—primarily due to acute and chronic rejection. The unique immunologic challenges of lung allografts, including constant environmental antigen exposure with each breath, largest organ being transplanted needing higher immunosuppresion and heightened susceptibility to ischemia-reperfusion injury, complicate conventional immunosuppressive approaches. Furthermore, infection-related complications and primary graft dysfunction (PGD)—a lung-specific complication—contribute substantially to morbidity and mortality. This article reviews current management strategies, delves into future towards better outcome, and presents a case of antibody-mediated rejection (AMR) following influenza infection, highlighting the complexities of post-transplant care.