Renal Transplant COPY

Question 1

Indications for Renal Transplant

Answer 1

Question 2

Contraindications to Renal Txp

Answer 2

Question 3

Evaluation for transplant recipient workup, labs, imaging, additional tests?

Answer 3

HCG (F < 50 yo)
CBC
PT/PTT
UA
Urine protein/creatinine
CMV
EBV
Varicella Zoster
Hep b
Hep C
HIV
Syphilis
Quantiferon Gold Tb or PPD
ABO type and antibody type (prior to sx)

Baseline CT A/P or US (non-contrast outlines calcifications in vessels)
Cardiac screening (EKG)
Dobutamine Stress test when > 3 risk factors (>60 yo , smoking, HTN, HLD< DMII, prior CVD, > 1 year on dialysis, LVH)\

Malignancy evaluation (5 year wait for invasive/mets, 1 year localized/low grade)

Question 4

GU evaluation prior to txp:

Answer 4

Evaluate voiding dysfunction: prostate scores, prostate US, UDS (not routine)

VUR → VCUG

CIC teaching

Asx urolithiasis generally not contraindication, may be risk for pyelo

Infective stones tx prior to txp

Question 5

In renal txp with recurrent UTI or systemic symptoms, what is part of workup? DDx?

Answer 5

BK virus (can reduce immunosuppression), viruia, bacteria

anatomic assessment important

Uroflow/PVR
UDS
US or CT (obstruction, abscess, stones, cysts)
VCUG (if suspect VUR)

Question 6

Risks of malignancy with immunosuppression?

Answer 6

Yes increased skin, lymphoma, kidney, bladder

ACKD → RCC (slight papillary predominance)

Question 7

Why is kidney preservation necessary? How is it done?

Answer 7

Cold storage
Pulsatile preservation pump (reduce vascular spasm, extend preservation time, reduce need for HD of txp)

Renal tubular Na-K pump maintains high intracellular K dependent on ATP

Ischemia leads to depletion of ATP, loss of cellular K and Mg, increased Ca, anaerobic glycolysis and acidosis, activation of enzymes

Reperfusion, hypoxanthine (a product of ATP) → xanthine → free radicals and cell damage

Question 8

What is ABO compatibility? Histocompatibility?

Answer 8

ABO blood groups are determined by cell surface carbohydrates on RBCs

Human major histocompatibility complex is a cluster of more than 200 genes on chromosome 6p21.31 responsible for HLA that are expressed as surface proteins on renal allograft

(most txp have some mismatch)

Question 9

Discuss HLA classification:

Answer 9

HLA Class 1: expressed on nucleated cells
HLA-A and HLA-B, class I antigens (as well as HLA-C)
present endogenous antigens to cytotoxic T-cells

HLA Class II: expressed on cells of immune system
HLA-DR is class II antigen (aw well as HLA-DQ and HLA-DP)
Present antigen to helper T-cells

Question 10

Live donor evaluations:

Answer 10

Healthy adults > 18 yo
no predisposing factors for CKD
w/o substance abuse or psych disorders

Normal surveillance screening (colonoscopy, PSA, mammogram, EKG)

Contrasted CT (size, shape, anatomic anomalies, number, length, location of arteries and veins)

Better kidney

Left with longer vein
Take kidney with fewer arteries

Question 11

What can you get HLA antibodies from?

Answer 11

prior blood txf, transplants, pregnancy

Question 12

Living donor operation key points:

Answer 12

low complication rate

hand-assisted Lap, full lap, robot (open rare)

ureter mobilized to point of crossing iliac

renal vessels ligated with stapler

extracted and placed in basin with iced saline

renal arteries cannulated

kidney flushed with ice-cold heparinized LR

Question 13

Indications for pre-txp Nx? Timeframe?

Answer 13

chronic or recurrent acute bacteria pyelo
infected stones
heavy proteinuria
intractable HTN
PCKD with markedly enlarged kidneys
infected reflux
renal cystic dz with concern of malignancy

6 weeks prior to Txp

Question 14

Significance of small bladder capacity in txp recipient?

Answer 14

Fibrosis or poor compliance may need pre-txp augment
small bladders may develop normal capacity and compliance post-txp unless fibrosis

Question 15

Describe Hand-Assist Lap Donor Nx:

Answer 15

1. NGT/Foley
2. Lateral (donor side up)
3. Camera trochar, additional under visualization
4. Introduce hand port through lower midline
5. Left Nx: mobilize descending colon, dissect ureter, open Gerota’s, dissect renal artery and vein, ligate adrenal vein and gonadal vein
6. Right Nx: mobilize ascending colon, dissect ureter, open Gerota’s, dissect renal artery and vein
7. Clip and cut ureter, staple artery and vein
8. Remove kidney via hand port
9. Flush with cold heparinized fluid
10. Check for bleeding
11. Close

Question 16

How do you manage 2 renal arteries

Answer 16

side-to-side anastomosis (“pair of pants”)

on back table (txp surgeon)

Question 17

For short allograft ureters, what are options:

Answer 17

Psoas hitch
Boari
Native UU
Native ureteropyelostomy
Pyelovesicostomy
Ileal ureter

Question 18

Post op transplant recipient care:

Answer 18

UOP
change in GFR
Electrolytes
CBC
Foley 3 days or longer

Hydration
Advance diet in 1- days (extraperitoneal)

US (if suspicion of vascular compromise)

Question 19

Immunosuppression 3 stages:

Answer 19

Work in synergy

Induction (lymphocyte depleting Ab or non-depleting Ab)
IV within 1 week of txp (Basiliximab)

Maintenance
3 categories (synergy) orally a few days after txp
Calcineurin-Inhibitor (tacrolimus, cyclosporin)
Antiproliferative agent (mycophenolic acid, azathioprine)
Co-stimulator blockade (Belatecept) MTOR (Sirolimus, Everolimus)
Corticosteroids (Prednisone)

Therapy for rejection
Rejection is lymphocyte mediated, can have Ab component
Corticosteroids
Lymphocyte depleting agents
If also Ab mediated (IVIG, Rituximab Bortezomib, Eculizumab, Plasmapheresis)

Question 20

types of rejection for kidney txp:

Answer 20

1. Hyperacute: immediately after revascularization due to pre-formed Ab → nx is required
2. Acute rejection: weeks to months, before sxs, dec UOP and elevated Cr, confirm renal bx, cellular or Ab mediated (classification system)
3. Chronic rejection (chronic allograph nephropathy): years, gradual decline in fx, bx → minimal mononuclear cell infiltration, fibrosis, vascular changes

Question 21

Complications following Renal Txp:

Answer 21

Immediate vascular: impair perfusion to kidney or distal extremity
Restoration may require intimal flap repair, dissection, thrombectomy, bypass
Late RAS restored via angioplasty/stent

Fistula (calyceal-cutenous) or stricture
Necrosis of distal ureter at implantation site
Decline UOP, rising Cr, pain, swelling, leakage from incision
May require revision
Strictures (ischemia) → hydro, endourologic vs. redo anastomosis

Lymphocele (common)
Hydro, obstruction, iliac vein compression, DVT
IR drain, OR drain

AUR
BPH (alpha blocker, 5ARI, sx - delay 1-2 mo)

Microhematuria
likely to be expected for 6 mo
after that time standard eval

Obstructing stones in allograft
PCN (with urosepsis or AKI)
4-5 mm conservative if GFR ok
Flexible URS superior to semi-rigid
1.5 cm PCNL (NO ESWL)

Question 22

Medical Complications after Renal Txp:

Answer 22

Infections
Opportunistic
Viral → BK, CMV, EBC, HSV, Hep B/C
Bacterial → nocardia, listeria, Tb
Fungal → pneumocystis, aspergillus, cryptococcus
Parasitic → strongyloides, toxoplasma, leishmania, trypanosoma

Immunosuppression can be reduced if graft function stable
Life threatening infection → stop immunosuppression

COVID 19

UTI

Cancer
Skin cancer (SCC and basal cell, melanoma)
Lympoma/Leukemia
Kaposi’s sarcoma
Uterus/Cervix
Angogenital
Renal

Nephrotoxicity, HTN, DMII, Neurotoxicity
GI (diarrhea, n/v)
Bone marrow suppression
Osteoporosis
Cataracts

Question 23

Immunosuppressant and side effects

Answer 23

Question 24

25 yo F with IDDM s/p renal txp in right iliac fossa, on cyclosporine, mycophenolate, prednisone, with fever 1-2 and pain, 3 days after txp, decreased UOP, what labs? Imaging?

Answer 24

Labs:

UA, UCx
CBC
BMP
Cyclosporine

Imaging:

KUB (stent)
Renal US (fluid, doppler)

Question 25

Ddx of perinephric fluid collection and decreased UOP days after txp? Test? Tx?

Answer 25

Hemorrhage from arterial or venous anastomosis

Urinoma

Lymphocele

Put IR drain, send fluid
Cr
Culture/Stain
KOH (fungus)

CT cystogram or Contrast CT
Antegrade imaging via PCN (if not apparent)

Tx:
small leaks → foley +/- PCN or stent
persistent or large → anastomotic revision

Question 26

type of of ureteral anastomotic revision for txp kidney if necrosis, leakage?

Answer 26

Reimplantation
Ureteropyelostomy to native ureter, nx of native kidney (planned)
Ureteroureterostomy to native ureter
Boari flap
Vesicopyelostomy (anastomosis with renal pelvis of txp)
Veiscocalycostomy
Ileal Ureter

Question 27

What is the most cost-effective treatment for patients with end-stage renal disease?
a) Dialysis
b) Kidney transplantation
c) Chemotherapy
d) Radiation therapy

Answer 27

b) Kidney transplantation. Renal transplantation is the most cost-effective treatment for patients with end-stage renal disease and improves their chances of survival and their quality of life.

Question 28

What is the range of overall rates for urologic complications after renal transplantation?
a) 2-3%
b) 4-5%
c) 6-7%
d) 8-9.5%

Answer 28

d) 8-9.5%. Overall rates of urologic complications after renal transplantation range between 8% and 9.5%.

Question 29

What is the most common cause of urologic complications after renal transplantation?
a) Transplanted kidney
b) Transplanted ureter and ureterovesical anastomosis
c) Donor kidney
d) Donor ureter

Answer 29

b) Transplanted ureter and ureterovesical anastomosis. The majority of the urologic complications after renal transplantation are related to the transplanted ureter and ureterovesical anastomosis.

Question 30

Why is prompt management of urologic complications important after renal transplantation?
a) To improve graft function
b) To prevent deterioration of graft function
c) To improve graft survival
d) All of the above

Answer 30

d) All of the above. Prompt management of urologic complications after renal transplantation is important to prevent deterioration of graft function, improve graft function, and improve graft survival.

Question 31

Which medical specialty is responsible for managing urologic complications after renal transplantation?
a) Cardiology
b) Urology
c) Oncology
d) Dermatology

Answer 31

b) Urology. Urologic complications after renal transplantation are the most common surgical adverse event, and the goal of this chapter is to help the urologist manage these complications.

Question 32

What is hematuria typically related to during the immediate postoperative period after a renal transplant?
a) Arteriovenous collecting system fistula
b) Donor kidney
c) Ureterovesical anastomosis
d) BK virus

Answer 32

c) Ureterovesical anastomosis. Hematuria during the immediate postoperative period after a renal transplant is typically related to the ureterovesical anastomosis.

Question 33

In what percentage of cases do arteriovenous collecting system fistulas tend to resolve spontaneously?
a) 20%
b) 50%
c) 70%
d) 90%

Answer 33

c) 70%. In 70% of cases, arteriovenous collecting system fistulas tend to resolve spontaneously.

Question 34

How is the diagnosis of an arteriovenous collecting system fistula confirmed?
a) Duplex ultrasound
b) Magnetic resonance imaging
c) Computed tomography
d) X-ray

Answer 34

a) Duplex ultrasound. The diagnosis of an arteriovenous collecting system fistula can be established by duplex ultrasound, which can be confirmed by magnetic resonance angiography.

Question 35

What is the biggest difference in evaluating asymptomatic microscopic hematuria in transplant recipients compared to non-transplant patients?
a) The causes of hematuria
b) The type of diagnostic tests used
c) The duration of observation
d) The location of the hematuria

Answer 35

a) The causes of hematuria. The evaluation of asymptomatic microscopic hematuria (AMH) in transplant recipients follows the American Urology Association guidelines for AMH, with the biggest difference being the addition of BK virus as part of the differential diagnosis.

Question 36

How is BK virus suspected and confirmed as a cause of asymptomatic microscopic hematuria in transplant recipients?
a) By viral cytopathic changes seen on cytology and confirmed by urine BK virus titers
b) By performing a biopsy of the transplanted kidney
c) By performing a duplex ultrasound
d) By performing a magnetic resonance angiography

Answer 36

a) By viral cytopathic changes seen on cytology and confirmed by urine BK virus titers. BK virus as a cause of asymptomatic microscopic hematuria in transplant recipients may be suspected by viral cytopathic changes seen on cytology and confirmed by urine BK virus titers.

Question 37

What is the utility of a ureteral stent across the ureterovesical anastomosis during renal transplantation?
a) To increase the incidence of urine leak
b) To decrease the incidence of urine leak and stricture of the ureter
c) To increase the risk of bacterial colonization
d) To decrease the risk of graft infection and graft failure

Answer 37

b) To decrease the incidence of urine leak and stricture of the ureter. Several randomized clinical trials confirmed the utility of the routine use of a ureteral stent across the ureterovesical anastomosis during renal transplantation to decrease the incidence of urine leak and stricture of the ureter.

Question 38

What is the risk of bacterial colonization associated with ureteral stent insertion?
a) 10%
b) 27%
c) 50%
d) 70%

Answer 38

b) 27%. Ureteral stent insertion is associated with an intrinsic risk of bacterial colonization, with 27% of the ureteral stents being colonized regardless of the indwelling time.

Question 39

What is the risk of graft infection and graft failure associated with subsequent urinary tract infection after ureteral stent insertion?
a) Low
b) Moderate
c) High
d) Very high

Answer 39

c) High. Subsequent urinary tract infection (UTI) after ureteral stent insertion may pose a significant risk for graft infection and graft failure.

Question 40

According to a recent meta-analysis, what is the effect of early stent removal on the incidence of urinary tract infection?
a) Increases the incidence of UTI
b) Has no effect on the incidence of UTI
c) Reduces the incidence of UTI
d) Eliminates the risk of UTI

Answer 40

c) Reduces the incidence of UTI. Early stent removal, defined by removal of the stent before the third postoperative week (before day 15), has been shown to reduce the incidence of UTI without discernible effect on the incidence of urine leak and stenosis.

Question 41

What factors should be taken into consideration for the timing of stent removal for every patient after renal transplantation?
a) Surgeon satisfaction with the anastomosis and the patient’s related risk factors such as diabetes, transplant revision, and presence of UTI.
b) Patient’s age and sex
c) Blood type compatibility with the donor
d) Number of previous transplants

Answer 41

a) Surgeon satisfaction with the anastomosis and the patient’s related risk factors such as diabetes, transplant revision, and presence of UTI. A case-by-case approach to the timing of stent removal for every patient must take into consideration surgeon satisfaction with the anastomosis and the patient’s related risk factors such as diabetes, transplant revision, and presence of UTI.

Question 42

What is the cause of a retained stent after a ureteroneocystostomy closure during renal transplantation?
a) Stent encrustation
b) Bacterial colonization
c) Technical error during the anastomosis suture
d) Kidney denervation

Answer 42

c) Technical error during the anastomosis suture. A retained stent can be due to a technical error during the ureteroneocystostomy closure in which the anastomosis suture inadvertently has caught the stent.

Question 43

What is stent encrustation, and how common is it?
a) The growth of bacteria on the surface of the stent; it occurs in 90% of patients
b) The accumulation of minerals on the surface of the stent; it occurs in 5-10% of patients
c) The rupture of the stent; it occurs in 2-3% of patients
d) The migration of the stent; it occurs in 15-20% of patients

Answer 43

b) The accumulation of minerals on the surface of the stent; it occurs in 5-10% of patients. Stent encrustation is the accumulation of minerals on the surface of the stent, and its incidence ranges from 0 to 5.7%.

Question 44

Why do kidney transplant recipients rarely manifest the classical symptoms of ureteral obstruction?
a) Because they have a higher pain tolerance
b) Because they have a lower sensitivity to urinary tract infections
c) Because of renal allograft denervation
d) Because of their overall better health status

Answer 44

c) Because of renal allograft denervation. Kidney transplant recipients rarely manifest the classical symptoms of ureteral obstruction because of renal allograft denervation.

Question 45

What symptoms does a transplant recipient with an encrusted stent usually present with?
a) A rapid increase in urine output and decreased risk of urinary tract infections
b) A progressive decline in renal function, a decrease in urine output, and recurrent UTIs
c) A decrease in urine output and an increase in blood pressure
d) A significant decrease in pain tolerance and an increase in overall health status

Answer 45

b) A progressive decline in renal function, a decrease in urine output, and recurrent UTIs. A transplant recipient with an encrusted stent usually presents with a progressive decline in renal function, a decrease in urine output, and recurrent UTIs.

Question 46

What is the treatment for a retained stent caused by suture entrapment?
a) Endoscopic stitch transection
b) Antibiotic therapy
c) Immunosuppressive therapy
d) Conservative management

Answer 46

a) Endoscopic stitch transection. If the suture holds the stent, leaving the stent until the suture dissolves is an option versus endoscopic stitch transection.

Question 47

What is the first step of management for stent encrustation?
a) Percutaneous nephrolithotomy
b) Retrograde intrarenal renal surgery
c) Extracorporeal wave shock lithotripsy
d) Urinary diversion by a nephrostomy tube

Answer 47

d) Urinary diversion by a nephrostomy tube. The first step of management for stent encrustation is typically a urinary diversion by a nephrostomy tube, which will allow for decompression of the renal collecting system, improvement in renal function, as well as antegrade access.

Question 48

Why is a CT scan important in patients with stent encrustation?
a) To assess for ureteral obstruction
b) To assess for bacterial colonization
c) To assess encrustation burden and distribution
d) To assess for kidney denervation

Answer 48

c) To assess encrustation burden and distribution. A CT scan should be obtained in all patients with stent encrustation to assess encrustation burden and distribution, which will help guide the surgical approach.

Question 49

What is the purpose of a nephrostomy tube in the management of stent encrustation?
a) To remove the encrusted stent
b) To allow for antegrade access
c) To reduce the risk of urinary tract infections
d) To document the encrustation burden and distribution

Answer 49

b) To allow for antegrade access. A nephrostomy tube is used in the management of stent encrustation to allow for decompression of the renal collecting system, improvement in renal function, as well as antegrade access.

Question 50

What are some of the treatments for encrusted transplant stent?
a) Antibiotic therapy
b) Nephrostomy tube placement
c) Percutaneous nephrolithotomy, retrograde intrarenal renal surgery, and extracorporeal wave shock lithotripsy
d) Ureteral stent insertion

Answer 50

c) Percutaneous nephrolithotomy, retrograde intrarenal renal surgery, and extracorporeal wave shock lithotripsy. Different combinations of percutaneous nephrolithotomy, retrograde intrarenal renal surgery, and extracorporeal wave shock lithotripsy have been described to treat the encrusted transplant stent.

Question 51

What is the goal of treating encrusted transplant stent?
a) To remove the stent
b) To improve renal function
c) To prevent stent encrustation
d) To reduce the risk of ureteral obstruction

Answer 51

b) To improve renal function. The goal of treating encrusted transplant stent is to improve renal function by removing the encrusted stent and treating the underlying cause of stent encrustation.

Question 52

What is the purpose of a ureteral stent in renal transplantation?
a) To decrease the risk of bacterial colonization
b) To decrease ureteral stricture and urinary leak
c) To reduce the risk of stent encrustation
d) To improve team communication

Answer 52

b) To decrease ureteral stricture and urinary leak. The purpose of a ureteral stent in renal transplantation is to decrease ureteral stricture and urinary leak.

Question 53

When should duplex US be considered for hematuria after renal biopsy?
a) For all cases of post-op hematuria
b) For self-limiting hematuria
c) For severe or persistent hematuria
d) For hematuria due to ureteral stent

Answer 53

c) For severe or persistent hematuria. Duplex US should be considered for severe or persistent hematuria after renal biopsy to rule out arteriovenous fistula.

Question 54

When is the majority of post-op hematuria self-limiting?
a) Within the first few hours after surgery
b) Within the first few days after surgery
c) Within the first few weeks after surgery
d) Within the first few months after surgery

Answer 54

b) Within the first few days after surgery. The majority of post-op hematuria is self-limiting and resolves over several days.

Question 55

: When is individualized stent removal recommended after renal transplantation?
a) After 1 week post-transplantation
b) After 2 weeks post-transplantation
c) After 3 weeks post-transplantation
d) After 4 weeks post-transplantation

Answer 55

c) After 3 weeks post-transplantation. Individualized stent removal is recommended after 3 weeks post-transplantation, taking into consideration the surgeon satisfaction with the anastomosis and the patient’s related risk factors.

Question 56

Encrusted ureteral stent

Answer 56

Question 57

What is the most common early urologic complication after renal transplantation?
a) Ureteral stricture
b) Urinary tract infection
c) Urine leak
d) Hematuria

Answer 57

c) Urine leak. Urine leak is the most common early urologic complication after renal transplantation.

Question 58

What is the main risk factor for ureteral necrosis and urine leak?
a) Donor age
b) Extended criteria donors
c) Allograft with multiple arteries
d) Compromising the blood supply to the distal ureter during organ procurement

Answer 58

d) Compromising the blood supply to the distal ureter during organ procurement. Compromising the blood supply to the distal ureter during organ procurement is the main risk factor for ureteral necrosis and urine leak.

Question 59

What are some additional causes of urinary leak after renal transplantation?
a) Urinary tract infection
b) Ureteral stricture
c) Technical problem such as suture dehiscence, ureteric twisting, or kinking
d) Stent encrustation

Answer 59

c) Technical problem such as suture dehiscence, ureteric twisting, or kinking. Additional causes of urinary leak after renal transplantation can include technical problems such as suture dehiscence, ureteric twisting, or kinking.

Question 60

What is the incidence of urine leak after renal transplantation?
a) 0.1% to 1.2%
b) 1.2% to 8.9%
c) 8.9% to 12%
d) 12% to 15%

Answer 60

b) 1.2% to 8.9%. The incidence of urine leak after renal transplantation ranges from 1.2% to 8.9%.

Question 61

What is the most common cause of urine leak after renal transplantation?
a) Urinary tract infection
b) Technical problem
c) Ureteral necrosis
d) Bladder dysfunction

Answer 61

c) Ureteral necrosis. The main risk factor for ureteral necrosis and urine leak is compromising the blood supply to the distal ureter during organ procurement.

Question 62

What is a possible manifestation of early urine leak after renal transplantation?
a) Decreased serum creatinine
b) Increased urine output
c) Elevated serum creatinine
d) Low fluid output from the drain

Answer 62

: c) Elevated serum creatinine. Early urine leak after renal transplantation can be manifested as high fluid output from the drain with a concomitant decrease in urine output and an elevated serum creatinine.

Question 63

How can the diagnosis of fluid collection from urine leak be established?
a) Blood tests
b) Analysis of urine color
c) US or non-enhanced CT scan
d) X-ray

Answer 63

c) US or non-enhanced CT scan. The diagnosis of fluid collection from urine leak can be established by performing US or non-enhanced CT scan.

Question 64

What is a possible symptom of urine leak after renal transplantation if the drain has been removed or omitted?
a) Increased urine output
b) Normal serum creatinine
c) Fluid leak from the wound
d) Low abdominal pain

Answer 64

c) Fluid leak from the wound. If the drain has been removed or omitted, urine leak after renal transplantation can be evident as a fluid leak from the wound, wound dehiscence, scrotal swelling, and/or pelvic or abdominal pain.

Question 65

How can the diagnosis of urine leak be confirmed?
a) Blood tests
b) Urine culture
c) CT scan without contrast
d) Analysis of the content of the collection sampled by CT/US-guided aspiration or fluid from the drain or wound discharge

Answer 65

d) Analysis of the content of the collection sampled by CT/US-guided aspiration or fluid from the drain or wound discharge. The diagnosis of urine leak can be confirmed by analyzing the content of the collection sampled by CT/US-guided aspiration or fluid from the drain or wound discharge.

Question 66

What will be significantly higher in the fluid if it is urine?
a) White blood cells
b) Red blood cells
c) Sodium
d) Creatinine

Answer 66

d) Creatinine. If the fluid is urine, the creatinine in the fluid will be significantly higher than the serum creatinine.

Question 67

What is the initial goal of treatment for a urine leak after renal transplantation?
a) Remove the graft
b) Close the anastomosis
c) Divert urine away from the region of extravasation
d) None of the above

Answer 67

c) Divert urine away from the region of extravasation. The initial goal of treatment for a urine leak after renal transplantation is to divert urine away from the region of extravasation, improve graft function, and ameliorate the patient’s general status.

Question 68

What is the role of a nephrostomy tube in treating a urine leak after renal transplantation?
a) To perform an antegrade nephrostogram
b) To perform a retrograde stent placement
c) To perform an angiogram
d) To perform a CT scan

Answer 68

a) To perform an antegrade nephrostogram. A nephrostomy tube can be used to perform an antegrade nephrostogram and characterize the leak further. In addition, it provides access for antegrade stent placement.

Question 69

When is percutaneous drainage recommended in the treatment of a urine leak after renal transplantation?
a) When there is a substantial urinoma
b) When there is evidence of infection
c) When the urinoma causes ureteral obstruction
d) All of the above

Answer 69

d) All of the above. Percutaneous drainage is recommended in the treatment of a urine leak after renal transplantation when a substantial urinoma forms or causes ureteral obstruction or there is evidence of infection.

Question 70

What is the success rate of endourologic management of urine leaks after kidney transplant?
a) 50%
b) 75%
c) 87%
d) 100%

Answer 70

c) 87%. The success rate of the endourologic management of the urine leak after kidney transplant ranges between 36% and 87% at a mean follow-up of 35 months.

Question 71

When should early exploration and reconstructive surgery be offered to patients with a urine leak after renal transplantation?
a) For all cases
b) For cases with a small anastomotic leak
c) For cases with a proximal large leak or persistent leak despite maximal drainage
d) None of the above

Answer 71

c) For cases with a proximal large leak or persistent leak despite maximal drainage. Early exploration and reconstructive surgery should be offered to patients with a proximal large leak or persistent leak despite maximal drainage.

Question 72

What is the predominant cause of ureteral obstruction in patients greater than 3 months post-transplantation?
a) Stones
b) Ureteral Stricture
c) Lymphocele
d) Fibrosis related to immunosuppressant medications

Answer 72

b) Ureteral Stricture

Explanation: Strictures are the predominant cause of ureteral obstruction in patients greater than 3 months post-transplantation. They affect 1% to 9% of patients; early ureteral obstruction can be due to technical faults during the construction of the ureteroneocystostomy, such as not using a ureteral stent, anastomotic edema, redundant ureter length or extrinsic compression by lymphocele, hematoma, or abscess.

Question 73

What is the primary cause of ureteral stricture development?
a) Stones
b) Ischemia
c) Graft rejection phenomena
d) Chronic infection

Answer 73

b) Ischemia

Explanation: The primary cause of ureteral stricture development is ischemia. Other causes for stricture development are related to urine leak, a component of graft rejection phenomena, or chronic infection. Also, BK and cytomegalovirus have been linked to ureteral stricture formation.

Question 74

TABLE 88.1
Common Causes of Ureteral Obstruction

Answer 74

Question 75

How is the diagnosis of ureteral stricture typically established?

Answer 75

Antegrade nephrostogram or a Whitaker test may be needed to establish the diagnosis.

Explanation: The diagnosis of ureteral stricture should be considered when any deterioration of renal function is observed, especially when it is associated with hydronephrosis of the renal transplant. To establish the diagnosis, antegrade nephrostogram or a Whitaker test may be needed. These tests help to visualize the site and severity of the stricture, which can help guide the treatment plan.

Question 76

What endoscopic options are available to treat ureteral strictures?
a. Double-J stent insertion
b. Ureteral balloon dilation
c. Endoureterotomy using different variations (i.e., cold knife, holmium laser)
d. All of the above

Answer 76

d. All of the above are endoscopic options to treat ureteral strictures.

Question 77

What is the success rate of open surgical repair in treating ureteral strictures compared to endoscopic management?
a. Endoscopic management has a higher success rate than open surgical repair.
b. Both have the same success rate.
c. Open surgical repair has a higher success rate than endoscopic management.
d. It depends on the size and location of the stricture.

Answer 77

c. Open surgical repair has a higher success rate than endoscopic management in treating ureteral strictures.

Question 78

What is the primary cause of ureteral stricture development?
a) Stones
b) Infection
c) Ischemia
d) Graft rejection

Answer 78

c) Ischemia. The primary cause of ureteral stricture development is ischemia.

Question 79

What is the primary cause of ureteral stricture development?
a) Stones
b) Infection
c) Ischemia
d) Graft rejection

Answer 79

c) Ischemia. The primary cause of ureteral stricture development is ischemia.

Question 80

Which treatment option offers superior long-term results for ureteral strictures?

A) Antegrade stent placement
B) Retrograde stent placement
C) Endoureterotomy
D) Open reconstructive surgery

Answer 80

: D) Open reconstructive surgery. A variety of endourologic treatment options have been described to treat ureteral strictures; however, open reconstructive surgery offers superior long-term results.

Question 81

When should stricture be suspected in renal transplant patients?

A) At any time post-transplantation
B) Only in the first 3 months post-transplantation
C) Only after the first year post-transplantation
D) When there is hydronephrosis and decreased graft function

Answer 81

D) When there is hydronephrosis and decreased graft function. Stricture should be suspected in patients with hydronephrosis and decreased graft function.

Question 82

What is the incidence of vesicoureteral reflux (VUR) seen on voiding cystography after ureterovesical anastomosis?
a) Less than 1%
b) 50% to 86%
c) 10% to 20%
d) 30% to 40%

Answer 82

b) 50% to 86%

Explanation: Despite several modifications of the ureterovesical anastomosis to prevent vesicoureteral reflux, the incidence of VUR can be seen in 50% to 86% of cases on voiding cystography.

Question 83

What is the incidence of symptomatic or clinically significant VUR after ureterovesical anastomosis?
a) Less than 1%
b) 10% to 20%
c) 30% to 40%
d) More than 50%

Answer 83

a) Less than 1%

Explanation: Although VUR is common after ureterovesical anastomosis, the incidence of symptomatic or clinically significant VUR is less than 1%.

Question 84

What are the potential causes of VUR after ureterovesical anastomosis?
a) Technical errors during the ureteroneocystostomy anastomosis
b) Bladder outlet obstruction
c) High-pressure urine storage due to detrusor overactivity or reduced bladder compliance
d) All of the above

Answer 84

d) All of the above

Explanation: VUR can be related to technical errors during the ureteroneocystostomy anastomosis, bladder outlet obstruction, or high-pressure urine storage due to detrusor overactivity or reduced bladder compliance.

Question 85

What is the standard treatment for vesicoureteral reflux?
A. Observation
B. Medical therapy
C. Revision of the anastomosis or ureter-reimplantation
D. Nephrectomy

Answer 85

C. Revision of the anastomosis or ureter-reimplantation to the ipsilateral native ureter has traditionally been the standard treatment for vesicoureteral reflux (VUR).

Question 86

What is the success rate of endoscopic submucosal injection for VUR?
A. 10%
B. 30%
C. 50%
D. 90%

Answer 86

D. The success rate of endoscopic submucosal injection for VUR depends on the grade of reflux; it reaches 90% in grades I and II disease, whereas it is only 30% in high-grade disease.

Question 87

When should endoscopic submucosal injection be attempted for VUR?
A. Only in patients with high-grade VUR
B. Only in patients with clinically significant low-grade VUR
C. In patients with any grade of VUR
D. Endoscopic submucosal injection is not recommended for VUR.

Answer 87

B. Endoscopic submucosal injection should be attempted only in patients with clinically significant low-grade VUR. Patients with high-grade reflux or failed previous endoscopic treatment with persistent symptoms are best managed by reconstructive surgery.

Question 88

What is a lymphocele?

a) A rare type of cancer that affects the lymph nodes in the groin area
b) A condition where lymphatic fluid accumulates in the bladder
c) A pseudocyst containing lymphatic fluid around the transplanted kidney
d) A type of infection that occurs after kidney transplantation

Answer 88

c) A pseudocyst containing lymphatic fluid around the transplanted kidney.

Explanation: A lymphocele is a pseudocyst containing lymphatic fluid that forms around the transplanted kidney. It is covered by a hard fibrous capsule and can be radiographically evident in a significant number of transplant recipients. The incidence of symptomatic lymphocele is relatively low, but it can cause a range of symptoms such as lower limb edema, deterioration of graft function, bladder compression, fever, and deep vein thrombosis.

Question 89

What is the main cause of lymphocele formation after kidney transplantation?
a) Obesity
b) Extensive dissection of the lymphatics
c) Prolonged warm ischemia time
d) Acute rejection

Answer 89

b) Extensive dissection of the lymphatics around the iliac vessels of the recipient or renal vessels of the donor during the time of organ procurement surgery or back table preparation is the main cause of lymphocele formation after kidney transplantation.

Question 90

Which of the following is not a factor associated with lymphocele formation?
a) Recipient age
b) Use of prophylaxis low-molecular-weight heparin
c) Normal body mass index (BMI)
d) Redo-transplant

Answer 90

c) Normal body mass index (BMI) is not associated with lymphocele formation after kidney transplantation. Obesity, recipient age, use of prophylaxis low-molecular-weight heparin, delayed graft function, acute rejection, and redo-transplant are all factors associated with lymphocele formation.

Question 91

What imaging modalities can be used to confirm the presence of a fluid collection around the graft in a patient suspected of having a lymphocele?
a) Magnetic resonance imaging (MRI) only
b) Computed tomography (CT) scan only
c) Ultrasound (US) examination only
d) Both CT scan and US examination

Answer 91

d) Both CT scan and US examination

Explanation: Confirmation of the presence of a fluid collection around the graft can be determined on US examination or CT scan. These imaging modalities can help differentiate lymphocele from other fluid collections such as urinoma, seroma, or abscess. Biochemical and microbiological analysis of the fluid from the lymphocele can be obtained directly from the drain or the aspirate using a US-guided/CT-guided fine-needle percutaneous aspiration.

Question 92

What is the primary treatment for lymphoceles?
A) Observation only
B) Aspiration with or without sclerotherapy
C) Open decortication surgery
D) Drain placement
E) All of the above

Answer 92

B) Aspiration with or without sclerotherapy is the primary treatment for lymphoceles, as the majority of lymphoceles are asymptomatic and no treatment is required because they tend to resolve spontaneously.

Question 93

What is the success rate for laparoscopic drainage of lymphoceles?
A) 41%
B) 50%
C) 69%
D) 84%
E) 92%

Answer 93

E) The success rate for laparoscopic drainage of lymphoceles is 92%, according to the provided material.

Question 94

What is the estimated incidence of kidney stones in kidney transplant recipients?
a) 0.5%
b) 1.0%
c) 1.5%
d) 2.0%

Answer 94

b) 1.0%

Explanation: According to the passage, the estimated incidence of kidney stones in kidney transplant recipients is 1.0%.

Question 95

Which is the most common stone composition in kidney transplant recipients?
a) Uric acid stones
b) Struvite stones
c) Calcium-based stones
d) Cystine stones

Answer 95

c) Calcium-based stones

Explanation: As per the information given in the passage, calcium-based stones are the most common stone composition in kidney transplant recipients (67%).

Question 96

What are some factors that favor stone formation in kidney transplant patients?
a) Hyperparathyroidism, recurrent urinary tract infections, and metabolic abnormalities
b) Hypothyroidism, recurrent urinary tract infections, and metabolic abnormalities
c) Hyperparathyroidism, recurrent urinary tract infections, and metabolic normalities
d) Hyperthyroidism, recurrent urinary tract infections, and metabolic abnormalities

Answer 96

a) Hyperparathyroidism, recurrent urinary tract infections, and metabolic abnormalities

Explanation: According to the passage, some factors that favor stone formation in kidney transplant patients include secondary hyperparathyroidism, recurrent urinary tract infections, and metabolic abnormalities such as hypercalciuria, hyperuricosuria, hypocitraturia, or hyperoxaluria.

Question 97

What is a possible cause of voiding dysfunction in kidney transplant recipients?
A) High urine volume
B) Preexisting anatomic abnormalities
C) Age-related changes
D) Improper medication dosage

Answer 97

B) Preexisting anatomic abnormalities. According to the passage, voiding dysfunction in kidney transplant recipients may result from an intricate interaction between a small bladder capacity, preexisting anatomic abnormalities, and the direct effect of immunosuppression on bladder function.

Question 98

What should be included in the evaluation of patients with voiding dysfunction?
A) History of dental problems
B) Previous surgical procedures only
C) Complete physical examination
D) Visual examination only

Answer 98

C) Complete physical examination. As stated in the passage, evaluation of patients with voiding dysfunction should include a detailed history of urologic and neurologic disorders, previous urologic surgeries, and a complete urologic and gynecologic physical exam.

Question 99

Which standardized questionnaires are recommended to assess voiding dysfunction symptoms?
A) Geriatric Depression Scale and Brief Pain Inventory
B) International Continence Society and the International Prostate Symptom score
C) Epworth Sleepiness Scale and Patient Health Questionnaire-9
D) Fatigue Severity Scale and McGill Pain Questionnaire

Answer 99

B) International Continence Society and the International Prostate Symptom score. As mentioned in the passage, assessing the symptoms using standardized questionnaires from the International Continence Society and the International Prostate Symptom score is desirable in evaluating patients with voiding dysfunction.

Question 100

What further testing may be indicated for patients with voiding dysfunction?
A) Electroencephalogram
B) Chest X-ray
C) Uroflowmetry, urodynamic testing, and cystoscopy
D) Magnetic resonance imaging of the brain

Answer 100

C) Uroflowmetry, urodynamic testing, and cystoscopy. As mentioned in the passage, the indication for further testing such as uroflowmetry, urodynamic testing, and cystoscopy depends on individual risk factors and symptoms in patients with voiding dysfunction.

Question 101

What is the maximum bladder capacity in patients with voiding dysfunction after renal transplantation?
A) 500 mL
B) 400 mL
C) 300 mL
D) 200 mL

Answer 101

C) 300 mL. According to the passage, an intricate interaction between a small bladder capacity (<300 mL), preexisting anatomic abnormalities, and the direct effect of the immunosuppression on bladder function play a significant role in voiding dysfunction in kidney transplant recipients.

Question 102

What is the typical course of bladder capacity in anuric recipients after kidney transplantation?
A) It remains small indefinitely.
B) It grows rapidly and exceeds normal capacity.
C) It grows gradually and reaches normal capacity.
D) It is not affected by kidney transplantation.

Answer 102

C) It grows gradually and reaches normal capacity. According to the passage, the bladder capacity in anuric recipients tends to grow gradually to reach normal capacity after kidney transplantation, making efforts to increase the bladder capacity before transplantation unnecessary.

Question 103

When may patients with bladder symptoms after renal transplantation benefit from anticholinergics or botox?
A) When bladder capacity is insufficient
B) When bladder capacity is excessive
C) When there is evidence of low storage pressure
D) When there is evidence of high storage pressure

Answer 103

D) When there is evidence of high storage pressure. As mentioned in the passage, patients with bladder symptoms affecting their quality of life after renal transplantation may benefit from anticholinergics or botox if bladder capacity is insufficient or there is evidence of high storage pressure.

Question 104

What is the purpose of lower urinary tract augmentation or urinary diversion using an ileal conduit?
A) To increase bladder capacity
B) To decrease bladder capacity
C) To improve bladder sensation
D) To prevent bladder infections

Answer 104

A) To increase bladder capacity. As mentioned in the passage, patients with bladder symptoms affecting their quality of life after renal transplantation may benefit from lower urinary tract augmentation or urinary diversion using an ileal conduit if bladder capacity is insufficient.

Question 105

What is a potential disadvantage of using botox to treat bladder symptoms after renal transplantation?
A) It is ineffective in most patients.
B) It can cause bladder overactivity.
C) It can cause urinary retention.
D) It can cause bladder cancer.

Answer 105

C) It can cause urinary retention. Although botox can be effective in treating bladder symptoms after renal transplantation, it can also cause urinary retention as a potential side effect.

Question 106

What is a possible reason for bladder symptoms affecting the quality of life in renal transplant recipients?
A) High urine volume
B) Age-related changes
C) Preexisting anatomic abnormalities
D) Decreased bladder mass

Answer 106

D) Decreased bladder mass. According to the passage, an intricate interaction between a small bladder capacity (<300 mL), preexisting anatomic abnormalities, and the direct effect of the immunosuppression on bladder function by decreasing bladder mass play a significant role in voiding dysfunction in kidney transplant recipients.

Question 107

What is the estimated 3-year incidence of BPH among renal transplant patients?
A) 1.7%
B) 4.7%
C) 7.7%
D) 9.7%

Answer 107

D) 9.7%. As mentioned in the passage, the estimated 3-year incidence of BPH among renal transplant patients is 9.7%, which is higher than that in the general population.

Question 108

What is a potential consequence of untreated BPH in renal transplant patients?
A) Lower risk of urinary tract infection
B) Improved graft survival
C) Higher risk of urinary tract infection and graft loss
D) Improved renal function

Answer 108

C) Higher risk of urinary tract infection and graft loss. As mentioned in the passage, BPH has been shown to be associated with an increased risk of urinary tract infection and graft loss in renal transplant patients.

Question 109

What precautionary measures should be considered if preoperative evaluation or intraoperative findings suggest the presence of significant BPH in a renal transplant patient?
A) Starting patients on a beta-blocker
B) Starting patients on an alpha-blocker and aggressive treatment of constipation
C) Delaying the transplant surgery
D) Performing a TURP before transplant surgery

Answer 109

B) Starting patients on an alpha-blocker and aggressive treatment of constipation. As mentioned in the passage, if preoperative evaluation or intraoperative findings suggest the presence of significant BPH, precautionary measures such as starting patients on an alpha-blocker and aggressive treatment of constipation before removing the Foley catheter should be considered.

Question 110

When is it safe to perform TURP or holmium enucleation of the prostate in renal transplant patients?
A) Before transplant surgery
B) Within 2 weeks after transplant surgery
C) After 3 weeks posttransplant
D) Any time after the patient has recovered from transplant surgery

Answer 110

C) After 3 weeks posttransplant. As mentioned in the passage, TURP or holmium enucleation of the prostate has been reported to be safe and effective in renal transplant patients if performed at least 3 weeks posttransplant.

Question 111

Why should TURP be avoided in the first 2 weeks and in the presence of a ureteral stent after renal transplant surgery?
A) It is ineffective in these circumstances.
B) It can cause bladder overactivity.
C) It can cause urinary retention.
D) It has been associated with sepsis and death.

Answer 111

D) It has been associated with sepsis and death. As mentioned in the passage, TURP should be avoided in the first 2 weeks and in the presence of a ureteral stent after renal transplant surgery because it has been associated with devastating complications such as sepsis and death.

Question 112

What is the estimated prevalence of urinary incontinence among female recipients?
A) 10%
B) 18%
C) 28%
D) 36%

Answer 112

C) 28%. According to the passage, the estimated prevalence of urinary incontinence among female recipients is 28%.

Question 113

How does the diagnosis and treatment of stress incontinence in transplant patients compare to nontransplant patients?
A) It is less accurate and effective.
B) It is more complex and requires more invasive procedures.
C) It is similar to nontransplant patients.
D) It is not possible in transplant patients.

Answer 113

C) It is similar to nontransplant patients. The passage states that the diagnosis and treatment of stress incontinence in transplant patients are similar to nontransplant patients.

Question 114

Which of the following is a method for treating urinary incontinence in female recipients described in the passage?
A) Holmium enucleation of the prostate
B) Insertion of an artificial urinary sphincter prosthesis
C) Urodynamic testing
D) Kidney transplantation

Answer 114

B) Insertion of an artificial urinary sphincter prosthesis. The passage states that limited reporting in the literature supports the feasibility of insertion of an artificial urinary sphincter prosthesis in kidney transplant patients after radical prostatectomy.

Question 115

Which of the following methods for treating urinary incontinence in female recipients is not mentioned in the passage?
A) Tension-free vaginal tape (TVT)
B) Transobturator tape (TOT)
C) Sacral neuromodulation
D) Laparoscopic sacrocolpopexy

Answer 115

None of the above. All of the methods listed in the options are mentioned in the passage as feasible and safe for treating urinary incontinence in female recipients.

Question 116

What is the main limitation of the literature on the feasibility of insertion of an artificial urinary sphincter prosthesis in kidney transplant patients?
A) It is not safe.
B) It is not effective.
C) It is limited.
D) It is not feasible.

Answer 116

C) It is limited. The passage mentions that limited reporting in the literature supports the feasibility of insertion of an artificial urinary sphincter prosthesis in kidney transplant patients after radical prostatectomy.

Question 117

Fig. 88.3
Renal mass in transplanted kidney.

Answer 117

Question 118

How does the incidence of renal cell carcinoma (RCC) in transplant recipients compare to the general population?
A) The incidence of RCC is lower in transplant recipients.
B) The incidence of RCC is the same in transplant recipients and the general population.
C) The incidence of RCC is higher in transplant recipients.
D) The incidence of RCC is not affected by transplantation.

Answer 118

C) The incidence of RCC is higher in transplant recipients. According to the passage, the incidence of RCC is higher in transplant recipients than in the general population.

Question 119

What percentage of posttransplant cancers is represented by RCC?
A) 2.5%
B) 3%
C) 4.6%
D) 5%

Answer 119

C) 4.6%. As mentioned in the passage, RCC represents 4.6% of posttransplant cancers.

Question 120

What is the mean time to develop a de novo tumor in the graft in transplant recipients?
A) 13.1 months
B) 31.1 months
C) 113.1 months
D) 131 months

Answer 120

D) 131 months. The passage states that the mean time to develop a de novo tumor in the graft is 131 months.

Question 121

Which histology subtype of de novo RCC is most commonly reported in kidney graft tumors?
A) Clear cell carcinoma
B) Chromophobe carcinoma
C) Papillary carcinoma
D) Sarcomatoid carcinoma

Answer 121

C) Papillary carcinoma. According to the passage, papillary carcinomas are reported in 56% of kidney graft tumors.

Question 122

How does the treatment of RCC in kidney transplant patients compare to RCC in the general population?
A) The treatment is more invasive and aggressive in transplant patients.
B) The treatment is less effective in transplant patients.
C) The treatment is the same in transplant patients and the general population.
D) The treatment is not possible in transplant patients.

Answer 122

C) The treatment is the same in transplant patients and the general population. The passage states that the treatment of RCC in kidney transplant patients is similar to RCC in the general population.

Question 123

Fig. 88.4
Renal cell carcinoma management in kidney transplant patients.

Answer 123

Question 124

Is the incidence of prostate cancer in kidney transplant recipients similar to that in the general population?
A) Yes, it is similar.
B) No, it is higher in transplant recipients.
C) No, it is lower in transplant recipients.
D) It is unknown.

Answer 124

A) Yes, it is similar. As mentioned in the passage, the incidence of prostate cancer in kidney transplant recipients is similar to that in the general population.

Question 125

Is there a definite national recommendation for or against prostate cancer screening in kidney transplant recipients?
A) Yes, there is a recommendation for screening.
B) No, there is no recommendation for or against screening.
C) Yes, there is a recommendation against screening.
D) It is unknown.

Answer 125

B) No, there is no definite national recommendation for or against prostate cancer screening in kidney transplant recipients, except following the current guidelines for prostate cancer screening in the general population.

Question 126

What is the most common modality of treatment for prostate cancer in kidney transplant recipients?
A) Active surveillance
B) Radiation therapy
C) Chemotherapy
D) Surgical extirpation

Answer 126

D) Surgical extirpation. As mentioned in the passage, the most common modality of treatment for prostate cancer in kidney transplant recipients is surgical extirpation by any approach.

Question 127

What is the risk of developing bladder cancer in kidney transplant patients compared to the general population?
A) Similar risk
B) Slightly increased risk
C) Significantly increased risk
D) The risk is unknown.

Answer 127

C) Significantly increased risk. The passage states that kidney transplant patients are at a significantly increased risk of developing bladder cancer compared with the general population, with a SIR of 3.18.

Question 128

What is an important consideration when managing bladder cancer in kidney transplant recipients?
A) Whether to perform cystectomy or not.
B) Whether to use intravesical bacillus Calmette-Guerin.
C) Whether to use chemotherapy or radiation therapy.
D) Whether to perform immunosuppression.

Answer 128

B) Whether to use intravesical bacillus Calmette-Guerin. The passage states that intravesical bacillus Calmette-Guerin can be used in selected patients with high-risk non-muscle-invasive bladder cancer. The passage also mentions that muscle invasive bladder cancer can be treated with chemoradiotherapy or cystoprostatectomy and urinary diversion, but the important consideration in bladder cancer management for kidney transplant recipients is the use of intravesical bacillus Calmette-Guerin.

Question 129

Where do most kidney tumors develop in kidney transplant patients?
A) In the transplanted kidney
B) In both the transplanted kidney and the native kidney
C) Only in the native kidneys
D) It varies depending on the patient.

Answer 129

C) Only in the native kidneys. As stated in the key points, most of the kidney tumors develop in the native kidneys in kidney transplant patients.

Question 130

What are reasonable treatment options for prostate cancer in kidney transplant patients?
A) Surgery only
B) Radiation therapy only
C) Active surveillance, radiation, and surgery
D) None of the above

Answer 130

C) Active surveillance, radiation, and surgery. As stated in the key points, active surveillance, radiation, and surgery (open and minimally invasive) are all reasonable options to treat prostate cancer in kidney transplant patients.

Question 131

What is the risk of urothelial carcinoma (UC) in kidney transplant patients compared to the general population?
A) Similar risk
B) Slightly increased risk
C) Three-fold increased risk
D) It is unknown.

Answer 131

C) Three-fold increased risk. The key points state that kidney transplant recipients have a three-fold risk of urothelial carcinoma (UC) compared with the general population, and that it is biologically more aggressive.

Question 132

Clinical Vignette:
You are consulting on a newborn with enlarged, homogeneous, echogenic kidneys on ultrasound. What other condition should you most suspect?

A. Diverticulitis
B. Congenital hepatic fibrosis
C. Epilepsy
D. Bardet-Biedl syndrome

Answer 132

Correct Answer: B

Explanation:
ARPKD is characterized by large, homogeneous, echogenic kidneys in newborns and is associated with congenital hepatic fibrosis and biliary dysgenesis.

Memory Tool:
ARPKD - “A Really Big Kid’s Disease” to remember large kidneys, and “Born Congested” for congenital hepatic fibrosis.

Reference Citation:
ABLE 39.1, Paragraph 1

Rationale:
Understanding associated systemic manifestations is essential for managing cystic kidney diseases, as they often have extra-renal complications.

Question 133

Clinical Vignette:
A pediatric patient shows renal failure and is found to have cysts of the corticomedullary junction on imaging. What other extrarenal manifestation might you expect?

A. Retinitis pigmentosa
B. Adenoma sebaceum
C. Mental retardation
D. Pheochromocytomas

Answer 133

Correct Answer: A

Explanation:
Juvenile nephronophthisis often has associated retinitis pigmentosa (also known as Senior-Loken syndrome).

Memory Tool:
“Junior Needs CorticoMed Junction Cysts & Really Perfect Sight” - for Juvenile nephronophthisis, CorticoMedullary Junction cysts, and Retinitis Pigmentosa.

Reference Citation:
ABLE 39.1, Paragraph 3

Rationale:
In children, early diagnosis of extra-renal symptoms can have a significant impact on the treatment approach.

Question 134

Clinical Vignette:
A pediatric patient has angiomyolipomas in the kidney and has a history of seizures. What dermatological feature should be looked for during physical examination?

A. Retinal angiomas
B. Adenoma sebaceum
C. Bardet-Biedl syndrome
D. Hepatic fibrosis

Answer 134

Correct Answer: B

Explanation:
Tuberous Sclerosis (autosomal dominant) often presents with adenoma sebaceum in addition to kidney cysts and angiomyolipomas.

Memory Tool:
TS - “Tubular Skin bumps” for adenoma sebaceum.

Reference Citation:
ABLE 39.1, Paragraph 5

Rationale:
Recognizing dermatological features can assist in the quick diagnosis and management of this condition.

Question 135

Clinical Vignette:
A 25-year-old male presents with clear cell Renal Cell Carcinoma (RCC). What other associated symptom is most likely?

A. Intracranial (berry) aneurysms
B. Cerebellar hemangioblastomas
C. Congenital hepatic fibrosis
D. Epilepsy

Answer 135

Correct Answer: B

Explanation:
Tuberous Sclerosis (autosomal dominant) often presents with adenoma sebaceum in addition to kidney cysts and angiomyolipomas.

Memory Tool:
TS - “Tubular Skin bumps” for adenoma sebaceum.

Reference Citation:
ABLE 39.1, Paragraph 5

Rationale:
Recognizing dermatological features can assist in the quick diagnosis and management of this condition.

Question 136

Clinical Vignette:
A newborn is diagnosed with multicystic dysplastic kidney. What is the most unique characteristic of this condition?

A. Presents with nephron development
B. Is an inheritable disease
C. Minimal, if any, nephron development
D. Commonly associated with hepatic fibrosis

Answer 136

Correct Answer: C

Explanation:
Multicystic Dysplastic Kidney is characterized by minimal, if any, nephron development. It is the most frequent renal cystic disease in newborns.

Memory Tool:
MDK - “Many Dots, but no Kidney function” to remember the lack of nephron development.

Reference Citation:
ABLE 39.1, Paragraph 7

Rationale:
Understanding the unique characteristics of each cystic kidney disease helps differentiate them in clinical scenarios.

Question 137

Clinical Vignette:
A 35-year-old female presents with a benign cystic neoplasm in the kidney. What is a characteristic feature of this condition?

A. Common in males below the age of 4
B. Presents more often in females older than 30
C. Associated with retinitis pigmentosa
D. Develops after onset of renal failure

Answer 137

Correct Answer: B

Explanation:
Benign multilocular cysts present more often in females when they are older than 30 years.

Memory Tool:
BMC - “Beneath My Care, 30+ Females” to remember age and gender specificity.

Reference Citation:
ABLE 39.1, Paragraph 8

Rationale:
Knowing age and gender predilections can assist in narrowing down diagnoses.

Question 138

Clinical Vignette:
A 60-year-old male comes in for a routine checkup, and imaging reveals multiple simple cysts in the kidneys. What can you tell him about this condition?

A. Commonly associated with ESRD
B. Very common with increasing age
C. Likely to develop into RCC
D. Associated with hepatic fibrosis

Answer 138

orrect Answer: B

Explanation:
Simple cysts are very common in normal kidneys with increasing age.

Memory Tool:
SC - “Sixty’s Commonplace” to remember its prevalence in older age groups.

Reference Citation:
ABLE 39.1, Paragraph 9

Rationale:
Recognizing common conditions and reassuring patients about their benign nature is important in practice.

Question 139

Clinical Vignette:
A patient is found to have ectatic collecting ducts in the kidney on imaging. What is a unique feature of their condition?

A. Associated with epilepsy
B. Ectatic collecting ducts with usually normal nephrons
C. Common in newborns
D. Increases with the duration of ESRD

Answer 139

Correct Answer: B

Explanation:
Medullary Sponge Kidney is characterized by ectatic collecting ducts, but the nephrons are usually normal.

Memory Tool:
MSK - “My Sponge Keeps” to remember the presence of ectatic collecting ducts but normal nephrons.

Reference Citation:
ABLE 39.1, Paragraph 10

Rationale:
Understanding the unique characteristics can help you differentiate this condition from other kidney diseases.

Question 140

Clinical Vignette:
A patient with a long history of End-stage Renal Disease (ESRD) develops multiple cysts in the kidneys. What additional risk is present?

A. Intracranial (berry) aneurysms
B. Hepatic fibrosis
C. Occasionally RCC
D. Retinitis pigmentosa

Answer 140

Correct Answer: C

Explanation:
Acquired renal cystic disease often increases the risk of RCC with the duration of ESRD.

Memory Tool:
ARCD - “Always Raising Cyst Duration” to remember the increasing risk of RCC with ESRD duration.

Reference Citation:
ABLE 39.1, Paragraph 11

Rationale:
Understanding the long-term risks of acquired diseases allows for better patient management and vigilance.

Question 141

Clinical Vignette:
A newborn presents with large, homogeneous, echogenic kidneys. What chromosomal defect is most likely responsible?

A. Chromosome 6
B. Chromosome 16
C. Chromosome 9
D. Chromosome 4

Answer 141

Correct Answer: A

Explanation:
ARPKD is linked to a chromosomal defect on chromosome 6.

Memory Tool:
ARPKD- “Always 6 Rookies Play Kidney Doctors” to remember chromosome 6.

Reference Citation:
ABLE 39.1, Paragraph 1

Rationale:
Understanding genetic markers is crucial for diagnosis and potentially for familial counseling.

Question 142

Clinical Vignette:
A 40-year-old man presents with renal cysts and diverticulitis. What extrarenal manifestation is specifically NOT expected?

A. Liver cysts
B. Retinitis pigmentosa
C. Mitral valve prolapse
D. Intracranial (berry) aneurysms

Answer 142

Correct Answer: B

Explanation:
ADPKD does not have retinitis pigmentosa as an extrarenal manifestation, unlike Juvenile nephronophthisis.

Memory Tool:
ADPKD- “Adults Don’t Prefer Retinal Issues” to remember the lack of retinitis pigmentosa.

Reference Citation:
ABLE 39.1, Paragraph 2

Rationale:
Understanding what is not a feature of a disease can be just as important in narrowing down diagnoses.

Question 143

Clinical Vignette:
A young patient presents with renal cysts and a history of seizures. Which chromosome is implicated in the more common form of Tuberous Sclerosis?

A. TSC1: chromosome 9
B. TSC2: chromosome 16
C. PKD1: chromosome 16
D. Chromosome 3

Answer 143

Correct Answer: A

Explanation:
Tuberous sclerosis is often linked to TSC1 on chromosome 9.

Memory Tool:
TSC1 - “The 9 Scary Cysts” to remember chromosome 9.

Reference Citation:
ABLE 39.1, Paragraph 5

Rationale:
Chromosomal defects may provide insight into disease severity and progression, leading to targeted treatment options.

Question 144

Clinical Vignette:
A 28-year-old patient presents with clear cell Renal Cell Carcinoma (RCC). Which of the following extrarenal manifestations is most likely also present?

A. Hepatic fibrosis
B. Cerebellar hemangioblastomas
C. Diverticulitis
D. Epilepsy

Answer 144

Correct Answer: B

Explanation:
von Hippel-Lindau disease is associated with cerebellar hemangioblastomas along with clear cell RCC.

Memory Tool:
VHL - “Very High Likelihood of cerebellar hemangioblastomas” to remember the associated extrarenal manifestation.

Reference Citation:
ABLE 39.1, Paragraph 6

Rationale:
Knowing extrarenal manifestations can assist in forming a more holistic diagnosis and treatment plan.

Question 145

Clinical Vignette:
You encounter a newborn with renal maldevelopment showing diffuse cysts and remnants of early metanephros. What is unique about this condition?

A. It is inheritable
B. It is the most frequent renal cystic disease in newborns
C. Associated with retinitis pigmentosa
D. Commonly develops into RCC

Answer 145

Correct Answer: B

Explanation:
Multicystic Dysplastic Kidney is the most frequent renal cystic disease found in newborns.

Memory Tool:
MDK - “Mostly Diagnosed in Kids” to remember its high frequency in newborns.

Reference Citation:
ABLE 39.1, Paragraph 7

Rationale:
Understanding the epidemiology of diseases can guide diagnostic considerations in specific populations.

Question 146

Clinical Vignette:
A 60-year-old patient with End-Stage Renal Disease (ESRD) presents with diffuse cysts and adenomas in the kidneys. What is a unique characteristic of this condition?

A. It is autosomal dominant
B. It increases with the duration of ESRD
C. It is associated with cranial tumors
D. It is linked to chromosome 6

Answer 146

Correct Answer: B

Explanation:
Acquired renal cystic disease increases with the duration of ESRD.

Memory Tool:
ARCD - “Aging Really Causes Diffusion” to remember the increasing prevalence with longer ESRD duration.

Reference Citation:
ABLE 39.1, Paragraph 11

Rationale:
The ability to identify long-term risks in chronic conditions allows for better patient management.

Question 147

A 40-year-old patient with ADPKD comes in complaining of severe headaches. What other medical complication are they at highest risk for?

A. Cerebellar hemangioblastomas
B. Intracranial (berry) aneurysms
C. Epilepsy
D. Retinal angiomas

Answer 147

Correct Answer: B

Explanation:
ADPKD often presents with intracranial (berry) aneurysms as an extrarenal manifestation.

Memory Tool:
ADPKD - “Always Doing Painful Knots in the Brain” for intracranial aneurysms.

Reference Citation:
ABLE 39.1, Paragraph 2

Rationale:
Awareness of these associated risks helps in the holistic management of the disease.