Transplants, Immunology, and Oncology Flashcards
43yo man with a gangrenous gallbladder and Gram neg sepsis agrees to participate in a research study. an assay of tumor necrosis factor (TNF) is performed. which of the following is the origin of this peptide?
a. fibroblasts
b. damaged vascular endothelial cells
c. monocytes/macrophages
d. activated T lymphocytes
e. activated killer lymphocytes
C
TNF = by endotoxin-activated monocytes and macrophages.
- PMN activation and dgranulation
- increased nonspecific host resistance
- increased vascular permeability
- lymphopenia
- promotion of IL1, 2, 6
- capillary leak syndrome
- microvascular thrombosis
- anorexia & cachexia
- protective & adverse effects in sepsis.
49yo man who underwent liver transplantation 5y ago for alcoholic cirrhosis presents with a gradually increasing bilirubin level. he undergoes a liver biopsy, which demonstrates a paucity of bile ducts. which of the following is his best option for treatment?
a. increase his imunosuppression
b. administration of a monoclonal antibody against T cells.
c. exploratory laparotomy with hepatic arterial reconstruction
d. exploratory laparotomy with thrombectomy of the portal vein
e. retransplantation
E. chronic rejection
paucity = barely any bile ducts –> due to immune-mediated injury in the biliary epithelium “vanishing bile duct syndrome”
If portal vein thrombosis –> exploratory laparotomy and thrombecty
If hepatic arterial thrombosis (–> can lead to biliary structures secondary to ischemia) = reexploration adnd thrombectomy with revision of anastamosis
52yo woman with renal failure is listed as a transplant candidate. in order to assess the propriety of the transplant, which of the following combos represents how a cross-match is performed?
a. donor serum with recipient lymphocytes and complement
b. donor lymphocytes with recipient serum and complement
c. donor lymphocytes with recipient lymphocytes
d. recipient serum with a known panel of multiple donor lymphocytes
e. recipient serum with donor RBCs and complement.
B. Whether recipient has circulating Abx against donor HLA antigens
a. do see if the donor lymphocytes would attack the recipient/s serum - body?
b. or if the host’s lympcytes would attack the donor’s serum (transplant)
c. disaster
39yo woman presents with generalized malaise and lymphadenopathy. biopsy of a supraclavicular lymph node reveals non-Hodgkin lymphoma. 48h after initiation of chemotherapy. she develops a high grade fever and her lab studies demonstrates hyperkalemia, hyperphosphatemia, and hypocalcemia. which of the following cells mediate this syndrome
a. macrophages
b. cytotoxic T lymphocytes
c. natural killer cells
d. PMN leukocytes
e. helper T lymphcytes
B. cytotoxic T cells.
tumor lysis syndrome –> after initially of chemotherapy = due to destruction of tumor cells.
- tumor lysis = hyperkalemia; hyperphosphatemia
- precipitation of phosphate & Ca = hypocalcemia (opposite to PO4)
timeline - macrophages, natural killer cells, & PMNs act fastest
33yo diabetic man receives a renal allograft. the physicians choose cyclosporine as one of the antirejection meds. which of the following functions does cyclosporine A primarily inhibit?
a. macrophages function
b. antibody production
c. IL-1 production
d. IL-2 production
e. cytotoxic T cell effectiveness
D
IL-1, 2, 3, 4, 5
Hot T Bone stEAk
IL-2 = T cells
24yo woman presents with lethargy, anorexia, tachypnea, and weakness. lab studies reveal a BUN of 150, serum creatinine of 16, and K of 6.2. CXR shoes increased pulmonary vascularity and dilated heart. which of the following is the most appropriate management of this pt?
a. emergency kidney transplantation
b. creation and immediate use of a forearm arteriovenous fistula
c. placement of a catheter in the internal jugular vein and initiation of hemodialysis
d. a 100g protein / day diet
e. renal biopsy
C. needs to be more immediate. Fistula takes a while to get along
Indications for dialysis A = acidosis E = excess I = intoxication O = overload of fluids U = uremia
a hypertensive 47yo man is proposed for kidney transplantation. he is anemic but is otherwise functional. which of the following would preclude renal transplantation
a. positive cross-match
b. donor blood type O
c. 2-antigen HLA match with donor
d. BP of 180/100 mmHg
e. Hgb of 8.2
A. positive cross-match = recipient has circulating Abs that are cytotoxic to donor-strain lymphcytes –> will lead to acute rejection of graaft
hypertensive due to what reason? - most common = renal stenosis. don’t want to risk the new kidney if have something intrinsically wrong
low Hgb likely because of bad kidney
56yo woman is undergoing a cadaveric renal transplant. after revascularization of the transplanted kidney, the transplanted renal parenchyma becomes swollen and blue. the surgeon suspects hyperacute rejection. what is the treatment of choice for this pt?
a. there is no therapy for hyperacute rejction
b. systemic anticoagulation
c. catheter-directed anticoagulation into the renal artery
d. IV steroids
e. IV steroids & cyclosporine
A. hyperacute rejection - within minutes after transplantation (preformed antibody). usually occurs during surgery after the clamps are released from teh vascular anastamosis & recipient Abs are exposed to donor passenger lymphocytes and kidney tissue.
can’t do anything - take out the kidney
56 yo man has end-stage heart failure due to atherosclerosis. his cardiologist refers him for evaluation for heart transplantation. which of the following is an absolute contraindication for heart transplantation?
a. cirrhosis
b. age > 65
c. diabetes w/out end-organ damage
d. reversible high pulmonary vascular resistance
e. hx of colon cancer resected 5y ago with no evidence of recurrence.
A
b/c can lead to RHF
Contraindications to heart transplant
- high, irreversible pulmonary vascular resistance
- irreversible renal insufficiency
- DM with end-organ damage
- symptomatic extravascular dx
- current / recent malignancy (<2y)
- noncardiac comorbidity limiting survival = cirrhosis, symptomatic COPD)
- active infection
- active PUD
- high risk for inability to comply with medical regimen
the others are relative contraindications
47yo man with hypertensivee nephropathy develops fever, graft tenderness, and oligura 4w following cadaveric renal transplantation. serum creatinine is 3.1. a renal U/S reveals mild edema of renal papilla but normal flow in both the renal artery and the renal vein. nuclear scan demonstrates sluggist uptake and excretion.
a. perform an angiogram
b. decreasing steroid and cyclosprine dose
c. begin IV antibiotics
d. perform renal biopsy, steroid boost, and Ig therapy
e. beginning FK 506.
D
Acute rejection (1w-3mo)? - the organ is failing.
the blood vessels look fine.
Dx = biopsy of renal tissue Tx = high dose steroids; anti-T cell Ab
approx 6w following a kidney transplant, a 59yo woman develops fever, malaise, and myalgias and is found to have a CMV infection. which of the following is a potential sequela of CMV infection?
a. pyelonephritis
b. GI ulceration and hemorrhage
c. cholecystitis
d. intra-abdominal abscess
e. parotitis
B
Gi hemorrhage, inflammation of any GI organs (including pancreas) blindness flu-like sxs electrolyte abnormalities dizziness / neurological sxs
bacterial infections = pyelonephritis, cholecystitis, intra-abdominal abscess, parotitis
55yo man presents with with worsening cirrhosis. after evaluation by a hepatologist, he presents for evaluation for hepatic transplantation. he is informed that prioritzation is based on the MELD score, and that patients with higher MELD scores have a greater benefit from transplantation. which of the following contributes to the MELD score?
a. platelet count
b. total bilirubin
c. albumin
d. encephalopathy
e. ascites
B
very numerically based
- tbili
- INR
- creatinine
DOES NOT assess based on subjective clinical parameters - degree of ascites / encephalopathy
a young woman who has received a transplant has posttransplant fever and malaise. GVHD is diagnosed. this has occurred most commonly with the transplantation of which of the following?
a. kidney
b. lung
c. heart
d. bone marrow
e. pancreas
D
- bone marrow / spleen –> b/c WBCs present in graft tissue
- liver
a brain dead potential donor has become available. you must plan for the dispersal of the thoracic organs. which of the following will necessitate a heart-lung transplant?
a. primary pulmonary HTN
b. cystic fibrosis
c. end-stage emphysema
d. idiopathic dilated cardiomyopathy with long-standing secondary pulmonary HTN
e. end-stage pulmonary fibrosis secondary to sarcoidosis
D
unexplained (primary, sarcoidosis) - means that their new transplants will also get affected
the others would require one but not the other
a 35yo man who has had T1DM for many years undergoes a pancreas transplant with enteric drainage (connection of the donor duodenum to the recipient jejunum). postop, he has increased pain near his pancreas transplant. which of the following should be performed to confirm a diagnosis of rejection?
a. percutaneous biopsy of the transplanted pancreas
b. measurement of serum amylase levels
c. measurement of serum lipase levels
d. measurement of urinary amylase levels
e. determination of the ratio of the level of urinary amylase to serum amylase
A
55yo woman who has end-stage liver disease is referred to a hepatologist for evaluation. which of the following would prevent her from a transplantation candidate?
a. use of EtOH 3 mo ago
b. two 2cm HCC in the R lobe of the liver
c. a 4cm HCC in the R lobe of the liver
d. development of the hepatorenal syndrome requiring hemodialysis
e. hx of breast cancer 5y ago w/ no evidence of disease currently
A
contraindications to liver transplant
- ongoing / recent substance abuse
- active sepsis infection
- extrahepatic malignancy
- poor cardiac / pulmonary fx
- HCC + metastatic dz
- obvious vascular invasion
- significant tumor burden
a kidney transplant recipient presents with severe acute rejection that does not respond to steroid treatment. administration of which of the following agents is the best step in her management?
a. cyclosporine
b. tacrolimus
c. azathioprine
d. muromonab-CD3
e. sirolimus
D
19yo college student presents with a testicular mass, and after treatment he returns for regular follow up visits. which of the following is the most useful serum amrker for detecting recurrent disease after treatment of nonseminomatous testicular cancer?
a. CEA
b. hCG
c. PSA
d. CA-125
e. p53 oncogene
B
nonseminomatous –> AFP, hcg, ldh
seminomatous –> hCG
edentulous 72 yo man with a 5y hx of cigarette smoking presents with a nontender hard mass in the lateral neck. which of the following is the best diagnostic test for establishing a diagnosis of malignancy
a. fine-need aspiration cytology
b. bone marrow biopsy
c. nasopharyngoscopy
d. CT scan of the head and neck
e. sinus xray
A
80% of isolated enlarged cervical lymph nodes in adults are malignant
- metastatic SCC
Dx = FNA
49yo woman undergoes surgical resection of a malignancy. the family asks about the prognosis. the histopathology is available for review. for which of the following malignancies does histologic grade best correlate with prognosis?
a. lung cancer
b. melanoma
c. colonic adenocarcinoma
d. hepatocellular carcinoma
e. soft tissue sarcoma
E
grade –> stage –> prognosis
tumors where histologic GRADING has prognostic value
- soft tissue sarcoma, TCC of bladder, astrocytoma, chondrosarcoma
tumors where STAGING has better prognostic value
- melanoma, HCC, osteosarcoma, lung, CRC
