Transplantation

Question 1

The most appropriate treatment of a lymphocoele following renal transplantation is

A. Observation until resolution

B. Percutaneous aspiration

C. Laparoscopic or open peritoneal window

D. Open exploration with sclerotherapy

Answer 1

?

Question 2

A positive crossmatch means:

A. There are no immunologic problems so one may proceed with the transplant

B. Will likely result in only mild rejection sometime after the 1st week

C. The recipient has preformed antibodies to donor antigens

D. Both the donor and recipient are CMV positive

Answer 2

?

Question 3

Hyperacute rejection following organ transplantation is most often due to:

A. ABO incompatibility

B. Rh incompatibility

C. Previous sensitized T cells

D. Macrophages

Answer 3

?

Question 4

Which of the following immunosuppressive drugs inhibits IL-2 synthesis?

A. Azathioprine

B. Mycophenolate mofetil

C. Tacrolimus

D. Sirolimus

Answer 4

?

Question 5

Post transplant lymphoproliferative disorder has been most commonly linked to:

A. HSV
B. RSV
C. EBV
D. Influenza virus

Answer 5

EBV

Question 6

Two weeks following kidney transplantation, a patient develops respiratory insufficiency requiring admission to the ICU. Chest x-ray shows diffuse infiltrations and bronchial washings show cells with inclusion bodies. The most appropriate therapy is:

A. Ganciclovir

B. Acyclovir

C. Bactrim

D. Penicillin

Answer 6

?

Question 7

A 35-year-old male POD 6 from a cadaveric renal transplantation develops a rise in creatinine. Ultrasound of the graft is normal. The biopsy shows acute tubulitis. This is consistent with?

A. Acute rejection

B. Urinary tract infection

C. Chronic rejection

D. Renal vein thrombosis

Answer 7

?

Question 8

Tacrolimus levels may be decreased in patients who are also taking:

A. Phenytoin
B. Erythromycin
C. Cimetidine
D. Fluconazole

Answer 8

?

Question 9

The most common etiology of liver failure in patients undergoing liver transplantation is:

A. Alcoholic cirrhosis

B. Metabolic disease

C. Chronic hepatitis

D. Fulminant (acute) liver failure

Answer 9

?

Question 10

Hyperacute rejection is caused by

A. Preformed antibodies
B. B-cell–generatedantidonorantibodies
C. T-cell–mediated allorejection
D. Nonimmunemechanism

Answer 10

Answer: A

Hyperacute rejection, a very rapid type o rejection, results in irreversible damage and graft loss within minutes to hours after organ reperfusion.

It is triggered by preformed antibodies against the donor’s human leukocyte antigen (HLA) or ABO blood group antigens.

These antibodies activate a series of events that result in diffuse intravascular coagulation, causing ischemic necrosis of the graft.

Fortunately, pretransplant blood group typing and cross-matching (in which the donor’s cells are mixed with the recipient’s serum, and then destruction of the cells is observed) have virtually eliminated the incidence of hyper acute rejection. (SeeSchwartz10thed.,p.324.)

Question 11

The mechanism of action of Azathioprine is:

A. Inhibition of calcineurin
B. Interference with DNA synthesis
C. Binding of FK-506 binding proteins
D. Inhibition of P7056 kinase

Answer 11

Answer: B

An antimetabolite, azathioprine (AZA) is converted to 6-mercaptopurine and inhibits both the de novo purine synthe- sis and salvage purine synthesis.

AZA decreases T-lymphocyte activity and decreases antibody production.

It has been used in transplant recipients or more than 40 years, but became an adjunctive agent after the introduction of cyclosporine. With the development of newer agents such as mycophenolate mofetil (MMF), the use of AZA has decreased significantly. However, it is preferred in recipients who are considering conceiving a child, because MMF is teratogenic in females and can cause birth defects. AZA might be an option or recipients who cannot tolerate the gastrointestinal (GI) side effects of MMF.

The most significant side effect of AZA, often dose-related, is bone marrow suppression.

Leukopenia is often reversible with dose reduction or temporary cessation of the drug. Other significant side effects include hepatotoxicity, pancreatitis, neoplasia, anemia, and pulmonary fibrosis. Its most significant drug interaction is with allopurinol, which blocks AZA’s metabolism, increasing the risk of pancytopenia.

Recommendations are to not use AZA and allopurinol together, or if doing so is unavoidable, to decrease the dose of AZA by 75%. (See Schwartz 10th ed., p. 326.)

Question 12

Which of the following is NOT a side effect of cyclosporine?

A. Interstitial fibrosis of the renal parenchyma
B. Gingival hyperplasia
C. Hirsutism
D. Pancreatitis

Answer 12

Answer: D
(See Schwartz 10th ed.,
Table 11-4, p. 327.)

Question 13

Post-renal transplant graft thrombosis usually occurs

A. Within 2 to 3 days
B. Within 2 weeks
C. Within 1 month
D. Within 3 months

Answer 13

Answer: A
One of the most devastating postoperative complications in kidney recipients is graft thrombosis. It is rare, occurring in fewer than 1% of recipients.

The recipient risk factors include a history of recipient hypercoagulopathy and severe peripheral vascular disease; donor-related risk actors include the use of enbloc or pediatric donor kidneys, procurement damage, technical factors such as intimal dissection or torsion of vessels, and hyperacute rejection. Graft thrombosis usually occurs within the first several days posttransplant.

Acute cessation of urine output in recipients with brittle posttransplant diuresis and the sudden onset of hematuria or graft pain should arouse suspicion of graft thrombosis.

Doppler ultrasound may help confirm the diagnosis. In cases of graft thrombosis, an urgent thrombectomy is indicated; however, it rarely results in graft salvage. (See Schwartz 10th ed., p. 339.)

Question 14

The 1-year graft survival after renal transplantation is

A. 35–40%
B. 50–55%
C. 75–80%
D. 92–96.5%

Answer 14

Answer: D

According to the 2010 Scientific Registry of Transplant Recipients (SRTR) annual report, a total of 84,614 adult patients were on the kidney transplant waiting list, including 33,215 added just that year.

Yet in 2009, only 15,964 adult kidney transplants were performed in the United States (9912 with a deceased donor and 6052 with a living donor). Of note, the number of patients added to the kidney transplant waiting list has increased every year, but the number of kidney transplants performed has been declining since 2006.

On the positive side, posttransplant outcomes have continued to improve: in 2009, the 1-year graft survival rate with a living donor kidney was 96.5%; with a deceased donor kidney, the rate was 92.0%. (See Schwartz 10th ed., p. 334.)

Question 15

After completion of the vascular anastomoses, drainage of a transplanted pancreas is accomplished by anastomosis to

A. Right colon
B. Left colon
C. Duodenum
D. Bladder or small bowel

Answer 15

Answer: D

Over the years, different surgical techniques have been described for (1) the management of exocrine pancreatic secretions and (2) the type of venous drainage.

For the secretions, the two most common techniques are drainage of the duodenal segment to the bladder (bladder drainage) or to the small bowel (enteric drainage) (Figs. 11-1 and 11-2).

For venous drainage, systemic venous drainage is preferred over portal venous drainage. (See Schwartz 10th ed., Figures 11-12 and 11-13, pp. 341–343.)

Question 16

All of the following are absolute contraindications in considering a candidate for orthotopic cardiac transplantation EXCEPT

A. Active infection
B. Age over 65 years
C. History of medical noncompliance
D. Severe pulmonary hypertension

Answer 16

Answer: B
In general terms, contraindications to a liver transplant include insu icient cardiopulmonary reserve, uncontrolled malignancy or infection, and refractory noncompliance.

Older age is only a relative contraindication: carefully selected recipients older than 70 years can achieve satisfactory outcomes.

Patients with reduced cardiopulmonary reserve are unlikely to survive a liver transplant. Candidates should have a normal ejection fraction.

If coronary arterial disease is present, they should undergo revascularization pretransplant.

Severe chronic obstructive pulmonary disease (COPD) with oxygen dependence is a contraindication.

Severe pulmonary hypertension with a mean pulmonary artery pressure greater than 35 mm Hg that is refractory to medical therapy is also a contraindication.

Candidates with pulmonary hypertension should be evaluated with a right heart catheterization. (See Schwartz 10th ed., p. 348.)

Question 17

Heart transplant donors and recipients are matched using the following criteria EXCEPT

A. Status on the UNOS waiting list
B. Gender
C. Bloodtype
D. Size

Answer 17

Answer: B
Once a potential deceased donor is identified, the surgeon reviews the status report and screening examination results. The donor is initially matched to the recipient per the recipient’s status on the UNOS waiting list, the size match, and the blood type.

Results o the donor’s serologic testing, echocardiography, chest X-ray, hemodynamic testing, and possibly coronary artery evaluation are assessed, in order to determine whether or not the donor’s heart can withstand up to 4 hours of cold ischemic time during procurement, transport, and surgery. (See Schwartz 10th ed., p. 355.)

Question 18

Required laboratory tests in evaluation o a patient under consideration or heart transplantation include all o the
ollowing EXCEPT

A. Psychosocial evaluation
B. Cardiac catheterization
C. Dental examination
D. All of the above

Answer 18

Answer: D
Pretransplant, both candidates and potential donors are evaluated to ensure their suitability or the procedure.

Transplant candidates undergo echocardiography, right and left heart catheterization, evaluation for any undiagnosed malignancies, laboratory testing to assess the function of other organs (such as the liver, kidneys, and endocrine system), a dental examination, psychosocial evaluation, and appropriate screening (such as mammography, colonoscopy, and prostate-specific antigen testing).

Once the evaluation is complete, the selection committee determines, at a multidisciplinary con er- ence, whether or not a heart transplant is needed and is likely to be successful. Transplant candidates who meet all of the center’s criteria are added to the waiting list, according to the UNOS criteria, which are based on health status. (See Schwartz 10th ed., p. 355.)

Question 19

Immunologic rejection is mediated by the recipient’s

A. Eosinophils
B. Lymphocytes
C. Neutrophils
D. Plasma cells

Answer 19

Answer: B

Transplants between genetically nonidentical persons lead to recognition and rejection of the organ by the recipient’s immune system, if no intervention is undertaken.

The main antigens responsible or this process are part of the major histocompatibility complex (MHC).

In humans, these anti- gens make up the HLA system. he antigen-encoding genes are located on chromosome 6.

Two major classes of HLAs are recognized. They differ in their structure, function, and tissue distribution.

Class I antigens (HLA-A, HLA-B, and HLA-C) are expressed by all nucleated cells.

Class II antigens (HLA-DR, HLA-DP, and HLA-DQ) are expressed by antigen presenting cells (APCs)such as B lymphocytes, dendritic cells, macrophages, and other phagocytic cells.

The principal function of HLAs is to present the fragments of foreign proteins to lymphocytes. This leads to recognition and elimination of the foreign antigen with great specificity. HLA molecules play a crucial role in transplant recipients as well.

They can trigger rejection of a graft via two different mechanisms.

The most common mechanism is cellular rejection, in which the damage is done by activated lymphocytes. (See Schwartz 10th ed., p. 324.)

Question 20

In the prevention of graft rejection, Cyclosporine

A. Blocks transcription of interleukin-1 (IL-1) and
tumor necrosis factor-α (TNF-α)

B. Inhibits lymphocyte nucleic acid metabolism

C. Results in rapid decrease in the number of circulatory
lymphocytes

D. Selectively inhibits T-cell activation

Answer 20

Answer: D

The introduction of cyclosporine in the early 1980s dramatically altered the yield of transplantation by significantly improving outcomes after kidney transplantation.

Cyclosporine binds with its cytoplasmic receptor protein, cyclophilin, which subsequently inhibits the activity of calcineurin, thereby decreasing the expression of several critical-cell activation genes, the most important being for IL-2.

As a result, T-cell activation is suppressed. (See Schwartz 10th ed., p. 328.)

Question 21

The most common cause of renal failure in the United States is

A. Chronic glomerulonephritis
B. Chronic pyelonephritis
C. Diabetes mellitus
D. Obstructive uropathy

Answer 21

Answer: C

Diabetes and hypertension are the leading causes of chronic renal disease. Concomitant cardiovascular disease (CVD) is a common finding in this population.

An estimated 30% to 42% of deaths with a functioning kidney graft are due to CVD.

Therefore, assessment of the potential kidney transplant candidate’s cardiovascular status is an important part of the pre- transplant evaluation. (See Schwartz 10th ed., p. 335.)

Question 22

The best method of monitoring the development of rejection in a patient after cardiac transplantation is

A. Dipyridamole thallium study
B. Electrocardiogram
C. Endomyocardial biopsy
D. Ultrasound examination of the heart

Answer 22

Answer: C
The goal of immunosuppression is to prevent rejection, which is assessed by immunosuppressive levels and, early on, by endomyocardial biopsy. Both T-cell–mediated (cellular) and B-cell–mediated (antibody-mediated) rejection are monitored. (See Schwartz 10th ed., p. 356.)

Question 23

Absolute contraindications to renal transplantation
patient with chronic renal failure include all of the following EXCEPT

A. Chronic active hepatitis

B. Colorectal cancer

C. Psychiatric illness

D. Sickle cell disease

Answer 23

Answer: D

Active infection for the presence of a malignancy, active sub- stance abuse, and poorly controlled psychiatric illness are the few absolute contraindications to a kidney transplant.

Studies have demonstrated the overwhelming benefits of kidney transplants in terms of patient survival, quality of life, and cost-effectiveness, so most patients with end stage renal disease (ESRD) are referred to for consideration of a kidney transplant. However, to achieve optimal transplant outcomes, the many risks (such as the surgical stress to the cardiovas- cular system, the development of infections or malignancies with long-term immunosuppression, and the psychosocial and financial impacts on compliance) must be carefully balanced. (See Schwartz 10th ed., p. 334.)

Question 24

All of the following is true for living renal transplant EXCEPT

A. Donor’s kidneys with multiple renal arteries should be avoided.

B. The donor’s left kidney is preferable.

C. There is no medical benefit to the donor.

D. The intraperitoneal approach is most often used for
harvest.

Answer 24

Answer: B

The kidney, the first organ to be transplanted from living donors, is still the most common organ donated by these individuals.

The donor’s left kidney is usually preferable because of the long vascular pedicle.

Use of living donor kidneys with multiple renal arteries should be avoided, in order to decrease the complexity of the vascular reconstruction and to help avoid graft thrombosis.

Most donor nephrectomies are now performed via minimally invasive techniques, that is, laparoscopically, whether hand-assisted or not.

With laparoscopic techniques, an intraperitoneal approach is most common: it involves mobilizing the colon, isolating the ureter and renal vessels, mobilizing the kidney, dividing the renal vessels and the distal ureter [C6], and removing the kidney (Fig. 11-3).

Extensive dissection around the ureter should be avoided, and the surgeon should strive to preserve as much length of the renal artery and vein as possible. (See Schwartz 10th ed., Figure 11-4, pp. 332–333.)

Question 25

The single most important factor in determining whether to perform a transplant between a specific donor and recipient is

A. Mixed lymphocyte culture assays of the donor and
recipient

B. HLA types of the donor and recipient

C. ABO blood types of the donor and recipient

D. Peripheral T-cell count of the recipient

Answer 25

Answer: C

ABO blood typing and HLA typing (HLA-A, -B, and -DR) are required before a kidney transplant. The method of screening for preformed antibodies against HLAs (because of prior transplants, blood transfusions, or pregnancies) is evolving.

The panel-reactive antibody (PRA) assay is a screening test that examines the ability of serum from a kidney transplant candidate to lyse lymphocytes from a panel of HLA-typed donors.

A numeric value, expressed as a percentage, indicates the likelihood of a positive cross-match with a donor. A higher PRA level identifies patients at high risk for a positive cross-match and therefore serves as a surrogate marker to measure the difficulty of finding a suitable donor and the risk of graft rejection. (See Schwartz 10th ed., p. 336.)

Question 26

The most common diagnosis leading to a heart transplant is

A. COPD
B. Congenital heart disease
C. Ischemic dilated cardiomyopathy
D. Idiopathic dilated myopathy

Answer 26

Answer: C

The most common diagnosis leading to a heart transplant is ischemic dilated cardiomyopathy, which stems from coronary artery disease, followed by idiopathic dilated myopathy and congenital heart disease.

About 3000 patients are added to the waiting list each year. (See Schwartz 10th ed., p. 355.)

Question 27

All of the following are side effects of cyclosporine administration for prevention of organ rejection EXCEPT

A. Hyperkalemia
B. Hirsutism
C. Tremor
D. Bone marrow depression

Answer 27

Answer: D
The metabolism of cyclosporine is via the cytochrome P450 system, resulting in many significant drug interactions (see able 11-1).

Calcineurin inhibitors are nephrotoxic and constrict the afferent arteriole in a dose-dependent, reversible
manner (Table 11-2).

They can also cause hyperkalemia and hypomagnesemia.

Several neurologic complications, including headaches, tremor, and seizures, also have been reported.

Cyclosporine has several undesirable cosmetic effects, including hirsutism and gingival hyperplasia.

It is associated with a higher incidence of hypertension and hyperlipidemia than is tacrolimus. (See Schwartz 10th ed., able 11-5, p. 328.)

Question 28

All of the following are true of extracorporeal membrane oxygenation (ECMO) EXCEPT

A. Cannulation occurs after withdrawal of life support.

B. Minimizes ischemic injury to organs of cardiac death
donors.

C. Organs are perfused with warm oxygenated blood
after declaration of cardiac death.

D. Cannulation occurs before withdrawal of life support.

Answer 28

Answer: A

A new development to minimize ischemic injury to organs procured after cardiac death has been the application of declaration of cardiac death (DCD) differs in two key ways:
(1) cannulation occurs before withdrawal of life support and (2) organs are perfused via ECMO with warm oxygenated blood after declaration of cardiac death.

The initial experience with organs procured using ECMO has been encouraging. (See Schwartz 10th ed., p. 331.)

Question 29

The most significant side effect of sirolimus is

A. Anemia
B. Leukopenia
C. Impaired wound healing
D. Hypertriglyceridemia

Answer 29

Answer: D

One of the most significant side effects of sirolimus is hypertriglyceridemia, a condition that may be resistant to statins and fibrates.

Impaired wound healing (immediately post- transplant in particular), thrombocytopenia, leukopenia, and anemia also are associated with sirolimus, and these problems are exacerbated when it is used in combination with MMF. (See Schwartz 10th ed., p. 328.)