Lung transplantation US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Lung transplantation. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Lung transplantation US Medical PG Question 1: A 48-year-old Caucasian male suffering from ischemic heart disease is placed on a heart transplant list. Months later, he receives a heart from a matched donor. During an endomyocardial biopsy performed 3 weeks later, there is damage consistent with acute graft rejection. What is most likely evident on the endomyocardial biopsy?
- A. Granuloma
- B. Atherosclerosis
- C. Lymphocytic infiltrate (Correct Answer)
- D. Tissue necrosis
- E. Fibrosis
Lung transplantation Explanation: ***Lymphocytic infiltrate***
- Acute graft rejection, especially within weeks of transplantation, is characterized by a **cellular immune response** dominated by **T lymphocytes** invading the allograft.
- These lymphocytes target donor major histocompatibility complex (MHC) molecules, leading to myocyte damage and dysfunction, which would be visible as a lymphocytic infiltrate on biopsy.
*Granuloma*
- Granulomas are aggregates of **macrophages**, often seen in chronic inflammatory conditions like tuberculosis, sarcoidosis, or fungal infections.
- They are not typical findings in the context of acute allograft rejection.
*Atherosclerosis*
- Atherosclerosis is a disease of large and medium-sized arteries characterized by **plaque formation**, primarily involving lipid deposition and inflammation, which narrows the arterial lumen.
- While it can affect transplanted organs (e.g., transplant vasculopathy, a form of chronic rejection), it is not the primary mechanism or histological finding in **acute cellular rejection** occurring three weeks post-transplant.
*Tissue necrosis*
- While acute rejection can *lead* to tissue necrosis due to severe inflammation and ischemia, necrosis alone is a broad term and not the most specific or defining histological feature of acute cellular rejection.
- The preceding and primary histopathological hallmark of acute cellular rejection is the **inflammatory cell infiltrate**, particularly lymphocytes attacking the graft.
*Fibrosis*
- Fibrosis, or the deposition of excess connective tissue, is a characteristic feature of **chronic rejection** or chronic injury processes.
- It indicates long-standing damage and repair, which is unlikely to be the predominant finding in a biopsy three weeks after transplantation indicative of acute rejection.
Lung transplantation US Medical PG Question 2: A 31-year-old female receives a kidney transplant for autosomal dominant polycystic kidney disease (ADPKD). Three weeks later, the patient experiences acute, T-cell mediated rejection of the allograft and is given sirolimus. Which of the following are side effects of this medication?
- A. Nephrotoxicity, hypertension
- B. Hyperlipidemia, thrombocytopenia (Correct Answer)
- C. Nephrotoxicity, gingival hyperplasia
- D. Pancreatitis
- E. Cytokine release syndrome, hypersensitivity reaction
Lung transplantation Explanation: ***Hyperlipidemia, thrombocytopenia***
- **Sirolimus** (rapamycin) is an **mTOR inhibitor** commonly used in transplant immunology, which frequently causes **hyperlipidemia** (elevated cholesterol and triglycerides) and **thrombocytopenia** (low platelet count).
- Other common side effects include **myelosuppression** (leukopenia, anemia), **mouth ulcers**, and **impaired wound healing**.
*Nephrotoxicity, hypertension*
- **Nephrotoxicity** and **hypertension** are more characteristic side effects of **calcineurin inhibitors** like **tacrolimus** and **cyclosporine**, which are also used in transplant immunosuppression but have a different mechanism of action than sirolimus.
- While sirolimus can indirectly affect kidney function, it is generally considered less nephrotoxic than calcineurin inhibitors.
*Nephrotoxicity, gingival hyperplasia*
- **Gingival hyperplasia** is a hallmark side effect of **cyclosporine**, a calcineurin inhibitor, along with **hirsutism** and **nephrotoxicity**.
- Sirolimus does not typically cause gingival hyperplasia.
*Pancreatitis*
- While some immunosuppressants can rarely cause pancreatitis, it is not a common or characteristic side effect of **sirolimus**.
- **Azathioprine** is more frequently associated with pancreatitis among immunosuppressive agents.
*Cytokine release syndrome, hypersensitivity reaction*
- **Cytokine release syndrome** and acute **hypersensitivity reactions** are more often associated with **monoclonal antibodies** (e.g., **basiliximab**, **daclizumab**) used for induction therapy or treatment of acute rejection, particularly within hours or days of administration.
- Sirolimus is less likely to cause these immediate severe reactions.
Lung transplantation US Medical PG Question 3: A 40-year-old male with a history of chronic alcoholism recently received a liver transplant. Two weeks following the transplant, the patient presents with a skin rash and frequent episodes of bloody diarrhea. A colonoscopy is performed and biopsy reveals apoptosis of colonic epithelial cells. What is most likely mediating these symptoms?
- A. Donor T-cells (Correct Answer)
- B. Recipient T-cells
- C. Recipient B-cells
- D. Recipient antibodies
- E. Donor B-cells
Lung transplantation Explanation: ***Donor T-cells***
- This clinical presentation of **skin rash**, **bloody diarrhea**, and **colonic epithelial apoptosis** following an allogeneic transplant (like a liver transplant) is classic for **Graft-versus-Host Disease (GVHD)**.
- In GVHD, **immunocompetent T-cells from the donor** recognize the recipient's tissues as foreign and mount an immune attack, causing damage to organs like the skin, gastrointestinal tract, and liver.
*Recipient T-cells*
- **Recipient T-cells** are typically immunosuppressed following an organ transplant to prevent organ rejection.
- Furthermore, if activated, recipient T-cells would target the donor organ (the liver in this case), leading to **rejection**, rather than the systemic symptoms observed (skin rash, bloody diarrhea) which suggest an attack by donor cells on recipient tissues.
*Recipient B-cells*
- While recipient B-cells can be involved in **antibody-mediated rejection** of the transplanted organ, they are not the primary mediators of **cellular GVHD**.
- **Antibody-mediated rejection** would typically involve antibodies targeting the donor liver, leading to liver dysfunction, not the widespread GVHD symptoms described.
*Recipient antibodies*
- **Recipient antibodies** are primarily involved in **antibody-mediated rejection** of the transplanted organ, which would manifest as dysfunction of the transplanted liver.
- They do not mediate the symptoms of **Graft-versus-Host Disease (GVHD)**, which is a cell-mediated immune response.
*Donor B-cells*
- **Donor B-cells** are generally not the primary mediators of GVHD.
- While donor immune cells are crucial for GVHD, the major players are **donor T-cells**, which directly recognize and attack host tissues.
Lung transplantation US Medical PG Question 4: A 24-year-old male with cystic fibrosis is brought to the emergency room by his mother after he had difficulty breathing. He previously received a lung transplant 6 months ago and was able to recover quickly from the operation. He is compliant with all of his medications and had been doing well with no major complaints until 2 weeks ago when he began to experience shortness of breath. Exam reveals a decreased FEV1/FVC ratio and biopsy reveals lymphocytic infiltration. Which of the following components is present in the airway zone characteristically affected by the most likely cause of this patient's symptoms?
- A. Pseudostratified columnar cells
- B. Goblet cells
- C. Simple cuboidal cells (Correct Answer)
- D. Stratified cuboidal cells
- E. Cartilage
Lung transplantation Explanation: ***Simple cuboidal cells***
- The patient's symptoms, history of a lung transplant, and biopsy findings of **lymphocytic infiltration** suggest **bronchiolitis obliterans**, a form of chronic lung allograft dysfunction.
- Bronchiolitis obliterans primarily affects the **small airways** (bronchioles), which are characterized by an epithelial lining of **simple cuboidal cells** and lack cartilage.
*Pseudostratified columnar cells*
- These cells line the **trachea** and **main bronchi** (larger airways), which are typically not the primary site of damage in bronchiolitis obliterans.
- They are part of the **mucociliary escalator** and are also associated with cartilage.
*Goblet cells*
- While present in the **larger airways** along with pseudostratified columnar cells, goblet cells are less prominent or absent in the small bronchioles primarily affected by bronchiolitis obliterans.
- Their characteristic function is mucus production, not the specific epithelial type of the affected bronchioles.
*Stratified cuboidal cells*
- This cell type is **rare** in the respiratory tract and is not characteristic of the small airways affected by bronchiolitis obliterans.
- Stratified epithelia are typically seen in ducts of glands or specialized transitional zones, not the functional bronchioles.
*Cartilage*
- Cartilage provides structural support to the **trachea and main bronchi**, but it is **absent** in the small airways (bronchioles) that are the primary target of bronchiolitis obliterans.
- The presence of cartilage would indicate a larger airway, contradicting the pathophysiology of this condition.
Lung transplantation US Medical PG Question 5: An investigator studying immune-mediated pulmonary damage performs an autopsy on a bilateral lung transplant recipient who died of hypercapnic respiratory failure. The patient underwent lung transplantation for idiopathic pulmonary fibrosis. Microscopic examination of the lung shows diffuse eosinophilic scarring of the terminal and respiratory bronchioles and near-complete luminal obliteration by polypoidal plugs of granulation tissue. Examination of the skin shows no abnormalities. The findings in this patient are most consistent with which of the following conditions?
- A. Acute graft rejection
- B. Recurrence of primary disease
- C. Transfusion-related acute lung injury
- D. Chronic graft rejection (Correct Answer)
- E. Acute graft-versus-host disease
Lung transplantation Explanation: ***Chronic graft rejection***
- Chronic rejection in lung transplant recipients classically manifests as **bronchiolitis obliterans**, characterized by diffuse **eosinophilic scarring** and **luminal obliteration** of small airways by polypoidal granulation tissue.
- This process leads to irreversible airflow obstruction and progressive respiratory failure, which aligns with the patient's death from **hypercapnic respiratory failure**.
*Acute graft rejection*
- Acute graft rejection typically presents with perivascular and interstitial mononuclear infiltrates, not necessarily diffuse eosinophilic scarring or luminal obliteration of bronchioles.
- While it can cause respiratory decline, the described microscopic features are more characteristic of a chronic process.
*Recurrence of primary disease*
- **Idiopathic pulmonary fibrosis** is characterized by usual interstitial pneumonia (UIP) pattern with patchy interstitial fibrosis, honeycombing, and fibroblast foci, which is distinct from the described bronchiolar scarring and obliteration.
- While IPF can recur, the histological findings described are not typical for recurrent IPF but rather for chronic rejection.
*Transfusion-related acute lung injury*
- **TRALI** is an acute lung injury reaction to blood products, usually occurring within 6 hours of transfusion, and is characterized by non-cardiogenic pulmonary edema.
- The described pathology of chronic scarring and obliteration is not consistent with the acute inflammatory and edematous changes seen in TRALI.
*Acute graft-versus-host disease*
- **Acute GVHD** primarily affects the skin, liver, and gastrointestinal tract; lung involvement is rare and typically presents as a diffuse interstitial pneumonitis.
- The absence of skin abnormalities and the specific bronchiolar pathology described do not fit the typical presentation of acute GVHD.
Lung transplantation US Medical PG Question 6: In which of the following pathological states would the oxygen content of the trachea resemble the oxygen content in the affected alveoli?
- A. Emphysema
- B. Exercise
- C. Pulmonary embolism (Correct Answer)
- D. Pulmonary fibrosis
- E. Foreign body obstruction distal to the trachea
Lung transplantation Explanation: ***Pulmonary embolism***
- A pulmonary embolism blocks **blood flow** to a portion of the lung, creating **dead space ventilation** (high V/Q ratio).
- In the affected alveoli, **no blood perfusion** means no oxygen extraction occurs, so the alveolar oxygen content remains **high and similar to tracheal/inspired air**.
- This is the classic physiological state where ventilation continues but perfusion is absent, preventing gas exchange.
*Foreign body obstruction distal to the trachea*
- A complete obstruction **prevents fresh air** from reaching the affected alveoli.
- The trapped gas undergoes **resorption atelectasis**: oxygen is absorbed into capillary blood, CO2 diffuses in, and alveolar gas equilibrates with **venous blood** composition.
- Alveolar oxygen content becomes **very low**, not similar to tracheal air.
*Emphysema*
- Emphysema involves destruction of **alveolar walls** and enlargement of airspaces with impaired gas exchange.
- While V/Q mismatch occurs, oxygen is still extracted by perfusing blood.
- Alveolar oxygen content is **lower than tracheal air** due to ongoing (though inefficient) gas exchange.
*Exercise*
- During exercise, **oxygen consumption increases** dramatically with enhanced cardiac output and oxygen extraction.
- Alveolar oxygen content is **significantly lower** than tracheal air due to increased oxygen uptake by blood.
*Pulmonary fibrosis*
- Pulmonary fibrosis causes **thickening of the alveolar-capillary membrane**, impairing oxygen diffusion.
- Despite diffusion limitation, blood still perfuses the alveoli and extracts oxygen.
- Alveolar oxygen content is **lower than tracheal air**, though the A-a gradient is increased.
Lung transplantation US Medical PG Question 7: A 58-year-old man is brought to the emergency department because of confusion, weight loss, and anuria. He has chronic kidney disease, hypertension, and type 2 diabetes mellitus. He was diagnosed with acute lymphoblastic leukemia at the age of 8 years and was treated with an allogeneic stem cell transplantation. He is HIV-positive and has active hepatitis C virus infection. He drinks around 8 cans of beer every week. His current medications include tenofovir, emtricitabine, atazanavir, daclatasvir, sofosbuvir, insulin, amlodipine, and enalapril. He appears lethargic. His temperature is 36°C (96.8°F), pulse is 130/min, respirations are 26/min, and blood pressure is 145/90 mm Hg. Examination shows severe edema in his legs and generalized muscular weakness. Auscultation of the lung shows crepitant rales. Laboratory studies show positive HCV antibody and positive HCV RNA. His HIV viral load is undetectable and his CD4+ T-lymphocyte count is 589/μL. Six months ago, his CD4+ T-lymphocyte count was 618/μL. An ECG of the heart shows arrhythmia with frequent premature ventricular contractions. Arterial blood gas analysis on room air shows:
pH 7.23
PCO2 31 mm Hg
HCO3- 13 mEq/L
Base excess -12 mEq/L
The patient states he would like to donate organs or tissues in the case of his death. Which of the following is an absolute contraindication for organ donation in this patient?
- A. HIV infection
- B. Childhood leukemia (Correct Answer)
- C. Alcoholism
- D. No absolute contraindications
- E. Acute kidney injury
Lung transplantation Explanation: ***Correct: Childhood leukemia***
- **History of hematologic malignancy** (including acute lymphoblastic leukemia) is an **absolute contraindication** for solid organ donation according to UNOS and OPTN guidelines.
- Even though this patient was treated 50 years ago with allogeneic stem cell transplantation, the concern for **residual malignant cells** or **transmission to immunosuppressed recipients** makes this an absolute exclusion.
- Unlike solid tumors (which may be acceptable after long disease-free intervals), **leukemias and lymphomas carry lifelong exclusion** from organ donation due to their systemic nature and potential for dormant cells.
*Incorrect: Acute kidney injury*
- **Acute kidney injury (AKI)** is NOT an absolute contraindication for organ donation.
- While the kidneys themselves may not be suitable for transplantation, other organs (heart, liver, lungs, corneas) could still be viable.
- Each organ is assessed individually for suitability.
*Incorrect: HIV infection*
- **Well-controlled HIV infection** (undetectable viral load, stable CD4 count >200) is no longer an absolute contraindication.
- Under the **HOPE Act (HIV Organ Policy Equity Act)**, organs from HIV-positive donors can be transplanted into HIV-positive recipients.
- This patient has excellent viral control (undetectable VL, CD4 589), making HIV not an absolute barrier.
*Incorrect: Alcoholism*
- **Alcohol use disorder** alone is not an absolute contraindication for organ donation.
- The suitability depends on individual organ assessment (e.g., liver function, cardiac health).
- This patient drinks 8 beers/week, which is moderate consumption and doesn't preclude donation of undamaged organs.
*Incorrect: No absolute contraindications*
- This patient **does have an absolute contraindication**: his history of hematologic malignancy (acute lymphoblastic leukemia).
- Despite the long time since treatment, hematologic cancers remain absolute exclusions for organ donation.
Lung transplantation US Medical PG Question 8: A 45-year-old man with a 5-year history of worsening shortness of breath and cough comes to the physician for a follow-up examination. He has never smoked. His pulse is 75/min, blood pressure is 130/65 mm Hg, and respirations are 25/min. Examination shows an increased anteroposterior diameter of the chest. Diminished breath sounds and wheezing are heard on auscultation of the chest. An x-ray of the chest shows widened intercostal spaces, a flattened diaphragm, and basilar-predominant bullous changes of the lungs. This patient is at increased risk for which of the following complications?
- A. Bronchogenic carcinoma
- B. Pulmonary fibrosis
- C. Pneumothorax (Correct Answer)
- D. Bronchiolitis obliterans
- E. Churg-Strauss syndrome
Lung transplantation Explanation: ***Pneumothorax***
- The patient's presentation with **worsening shortness of breath**, **increased anteroposterior diameter**, **diminished breath sounds**, and **basilar-predominant bullous changes** strongly suggests **Alpha-1 antitrypsin deficiency** (AATD) which causes panacinar emphysema.
- Patients with severe emphysema, particularly those with **large bullae**, are at significantly increased risk of developing a **spontaneous pneumothorax** due to the rupture of these fragile air sacs.
*Bronchogenic carcinoma*
- While smoking is a major risk factor for **bronchogenic carcinoma**, this patient has **never smoked**, making it less likely given his current symptoms.
- The imaging findings of **bullous changes** are more indicative of emphysema than neoplastic changes.
*Pulmonary fibrosis*
- **Pulmonary fibrosis** typically presents with a **restrictive lung disease pattern**, characterized by decreased lung volumes and often reticular changes on imaging.
- The patient's findings, such as an **increased anteroposterior diameter** and **flattened diaphragm**, are characteristic of **obstructive lung disease** (emphysema), not fibrosis.
*Bronchiolitis obliterans*
- **Bronchiolitis obliterans** is a rare obstructive lung disease often associated with **post-infectious sequelae**, connective tissue diseases, or following lung transplantation.
- The clinical and radiological findings are more consistent with **emphysema** due to Alpha-1 antitrypsin deficiency, rather than bronchiolitis obliterans.
*Churg-Strauss syndrome*
- **Churg-Strauss syndrome** (eosinophilic granulomatosis with polyangiitis) is a systemic vasculitis characterized by **asthma**, **eosinophilia**, and **extrapulmonary involvement**.
- While asthma can cause wheezing, the predominant radiological findings of **bullous emphysema** and the risk factors for pulmonary collapse are inconsistent with Churg-Strauss syndrome.
Lung transplantation US Medical PG Question 9: A 66-year-old man is transferred from another hospital after 3 days of progressively severe headache, vomiting, low-grade fever, and confusion. According to his partner, the patient has been dealing with some memory loss and complaining about headaches for the past 2 weeks. He has a history of interstitial pulmonary disease that required lung transplantation 2 years ago. Upon admission, he is found with a blood pressure of 160/100 mm Hg, a pulse of 58/min, a respiratory rate of 15/min, and a body temperature of 36°C (97°F). During the examination, he is found with oral thrush and symmetric and reactive pupils; there are no focal neurological signs or papilledema. A lumbar puncture is performed. Which of the following features would be expected to be found in this case?
- A. Aspect: clear, opening pressure: normal, cell count: < 5 cells/µL, protein: normal, glucose: normal
- B. Aspect: clear, opening pressure: normal, cell count: ↑ lymphocytes, protein: normal, glucose: normal
- C. Aspect: cloudy, opening pressure: ↑, cell count: ↑ neutrophils, protein: ↑, glucose: ↓
- D. Aspect: xanthochromic, opening pressure: normal, cell count: ↑ red blood cells, protein: normal, glucose: normal
- E. Aspect: clear, opening pressure: ↑, cell count: ↑ lymphocytes, protein: ↑, glucose: ↓ (Correct Answer)
Lung transplantation Explanation: ***Aspect: clear, opening pressure: ↑, cell count: ↑ lymphocytes, protein: ↑, glucose: ↓***
- This patient presents with symptoms highly suggestive of **cryptococcal meningitis**, a common opportunistic infection in immunocompromised individuals like transplant recipients.
- **Cryptococcal meningitis** characteristically presents with **clear CSF** (not cloudy, which differentiates it from bacterial meningitis), **markedly elevated opening pressure** (often >25 cm H₂O), **lymphocytic pleocytosis**, **elevated protein**, and **decreased glucose** due to fungal metabolism.
- The presence of **oral thrush** strongly suggests fungal infection in this immunocompromised patient.
*Aspect: clear, opening pressure: normal, cell count: < 5 cells/µL, protein: normal, glucose: normal*
- This describes **normal cerebrospinal fluid (CSF)** parameters, which would not be expected in a patient presenting with signs and symptoms of meningitis, such as headache, vomiting, fever, and confusion.
- The patient's history of lung transplantation and oral thrush suggests an immunocompromised state and an opportunistic infection, ruling out normal CSF.
*Aspect: clear, opening pressure: normal, cell count: ↑ lymphocytes, protein: normal, glucose: normal*
- While **increased lymphocytes** can be seen in aseptic or viral meningitis, the overall picture of normal opening pressure, protein, and glucose does not fit this immunocompromised patient with subacute meningitis.
- The presence of **oral thrush** and **2 weeks of symptoms** indicate a more severe opportunistic infection like cryptococcal meningitis, which would show elevated opening pressure and abnormal protein and glucose levels.
*Aspect: cloudy, opening pressure: ↑, cell count: ↑ neutrophils, protein: ↑, glucose: ↓*
- This CSF profile is characteristic of **bacterial meningitis**, which is primarily marked by **cloudy CSF** due to significant **neutrophilic pleocytosis**.
- While the patient is immunocompromised, the history of **subacute symptoms** (2 weeks of headache/memory loss) and gradual deterioration is more typical of a fungal infection like **cryptococcal meningitis** rather than acute bacterial meningitis, which presents more acutely.
*Aspect: xanthochromic, opening pressure: normal, cell count: ↑ red blood cells, protein: normal, glucose: normal*
- **Xanthochromic CSF** with **elevated red blood cells** indicates subarachnoid hemorrhage.
- While headache is present, the patient's symptoms of fever, progressive confusion, oral thrush, and immunocompromised status point away from a primary hemorrhagic event and towards an infectious etiology.
Lung transplantation US Medical PG Question 10: A 38-year-old kidney transplant recipient maintained on tacrolimus presents with a 2-week history of progressive confusion, ataxia, and visual disturbances. MRI shows multifocal white matter lesions without mass effect or enhancement. CSF analysis reveals mild pleocytosis with elevated protein. JC virus DNA is detected in CSF by PCR. Serum tacrolimus level is therapeutic at 8 ng/mL. Apply knowledge of this condition to determine the appropriate management strategy.
- A. Significantly reduce or discontinue immunosuppression and provide supportive care (Correct Answer)
- B. Switch from tacrolimus to sirolimus to preserve graft while treating infection
- C. Continue current immunosuppression and administer IVIG therapy
- D. Maintain immunosuppression and start cidofovir antiviral therapy
- E. Reduce tacrolimus by 50% and start high-dose corticosteroids
Lung transplantation Explanation: ***Significantly reduce or discontinue immunosuppression and provide supportive care***
- The patient presents with **Progressive Multifocal Leukoencephalopathy (PML)** caused by **JC virus** reactivation; the primary treatment is **immune reconstitution** to allow the body to fight the virus.
- Reducing or stopping agents like **tacrolimus** is critical for survival, even though it carries a high risk of **allograft rejection**.
*Switch from tacrolimus to sirolimus to preserve graft while treating infection*
- While **sirolimus** has some antiproliferative effects, it is still an **immunosuppressant** and will not allow for the aggressive immune recovery needed to halt **JC virus** replication.
- Managing the life-threatening neurological condition takes precedence over **graft preservation** in the acute phase of PML.
*Continue current immunosuppression and administer IVIG therapy*
- Maintaining current levels of **tacrolimus** prevents the T-cell mediated response necessary to clear the **JC virus** from the CNS.
- **IVIG therapy** has not been proven effective in clinical trials for the treatment of PML and does not address the underlying **immunosuppressed state**.
*Maintain immunosuppression and start cidofovir antiviral therapy*
- **Cidofovir** was previously studied for PML, but it has failed to show significant clinical benefit and is associated with severe **nephrotoxicity**.
- Antiviral therapy without addressing the **cellular immune deficiency** is insufficient to treat this opportunistic infection.
*Reduce tacrolimus by 50% and start high-dose corticosteroids*
- Adding **high-dose corticosteroids** is contraindicated as it further suppresses the immune system, potentially accelerating the progression of **PML**.
- Steroids are typically reserved only for patients who develop **Immune Reconstitution Inflammatory Syndrome (IRIS)** after immunosuppression is withdrawn.
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