Cardiac Transplantation Pathology — MCQs
Which of the following diseases is appropriately treated with combined heart-lung transplantation?
Which of the following statements about transplant rejection reactions is false:
Which of the following is category 3 in the Maastricht classification of donation after cardiac death?
The hypersensitivity reaction involved in the hyperacute rejection of a renal transplant is:
Feature NOT seen in acute rejection of transplanted kidney?
Which is the most common causative organism involved in infections after kidney transplantation?
'Triphasic waveform' on colour Doppler is of
Which of the following is least likely in PDA?
Aetiology of Dressler Syndrome is
An athlete collapsed and expired while playing school basketball. Histology of the cardiac specimen is most likely to indicate which of the following conditions?
Cardiac Transplantation Pathology Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following diseases is appropriately treated with combined heart-lung transplantation?
- A. End-stage emphysema
- B. Idiopathic dilated cardiomyopathy with long-standing secondary pulmonary hypertension (Correct Answer)
- C. Primary pulmonary hypertension
- D. Cystic fibrosis
Explanation: ***Idiopathic dilated cardiomyopathy with long-standing secondary pulmonary hypertension*** - In cases of severe **idiopathic dilated cardiomyopathy**, the failing left ventricle can lead to **long-standing secondary pulmonary hypertension**. - This persistent high pressure in the pulmonary circulation results in **irreversible damage** to the pulmonary vasculature, creating fixed pulmonary vascular resistance. - When the pulmonary hypertension becomes fixed and irreversible, isolated heart transplantation would fail as the new heart would face the same elevated pressures, necessitating **combined heart-lung transplantation**. *End-stage emphysema* - **End-stage emphysema** primarily affects the lungs, causing destruction of alveolar walls and airflow obstruction. - While a **bilateral lung transplant** is the standard treatment for severe emphysema, the heart is typically not primarily affected to the extent that it would require combined transplantation. *Primary pulmonary hypertension* - **Primary pulmonary hypertension** is a disease of the pulmonary arteries, where blood vessels in the lungs become narrowed, stiff, or destroyed. - In most cases, **bilateral lung transplantation** alone is sufficient, as the new lungs provide healthy pulmonary vasculature. - While combined heart-lung transplantation may be considered in severe cases with established irreversible right ventricular failure, the more definitive indication is when secondary pulmonary hypertension is caused by primary cardiac disease (as in option A). *Cystic fibrosis* - **Cystic fibrosis** is a genetic disorder that predominantly causes severe lung disease due to thick, sticky mucus buildup. - It primarily necessitates a **bilateral lung transplant** to replace the diseased lungs; the heart is generally not directly affected to the point of requiring a combined transplant.
Question 2: Which of the following statements about transplant rejection reactions is false:
- A. Acute rejection is readily reversible with appropriate treatment
- B. Liver is extremely sensitive to hyperacute rejection (Correct Answer)
- C. Hyperacute rejection is uncommon
- D. Chronic rejection is a major cause of late graft loss
Explanation: ***Hyperacute rejection is uncommon*** - Hyperacute rejection occurs within minutes of transplantation and is mostly associated with **pre-existing antibodies** against donor antigens, making it relatively rare with proper donor-recipient matching [1]. - Improvements in **cross-matching** techniques have led to a decrease in its incidence, reinforcing that it is not commonly encountered in modern transplants. *Acute rejection is readily reversible with appropriate treatment* - Acute rejection can be effectively treated but is not universally **reversible**, depending on the timing and severity of the rejection episode [1]. - It typically requires **immunosuppressive therapy** [2], which may not always fully restore graft function. *Chronic rejection invariably leads to loss of the graft* - Chronic rejection is a slower process that may not always lead to **immediate loss**, as some grafts can survive with reduced function for extended periods. - It's a progressive process often associated with **gradual dysfunction** rather than acute failure. *Liver is more resistant to Hyperacute rejection due to its dual blood supply.* - While the liver's dual blood supply can afford some protection, this characteristic does not completely **prevent** hyperacute rejection. - Other factors, such as the presence of **specific antibodies**, play a more significant role in hyperacute reactions than just blood supply. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 241-243. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 180-181.
Question 3: Which of the following is category 3 in the Maastricht classification of donation after cardiac death?
- A. Awaiting cardiac arrest (Correct Answer)
- B. Patient found deceased upon arrival
- C. Attempts at resuscitation after cardiac arrest
- D. Cardiac arrest following brain death declaration
Explanation: ***Awaiting cardiac arrest*** - This category denotes patients who are anticipated to have a **cardiac arrest** and are considered for organ donation after the cessation of circulatory function. - These individuals are typically in an **intensive care setting**, where withdrawal of life support is planned, leading to eventual cardiac death. *Patient found deceased upon arrival* - This describes individuals who have suffered **unwitnessed cardiac arrest** and are pronounced dead upon the arrival of medical personnel. - Organ viability for donation is often compromised due to the **unknown downtime** and lack of controlled conditions. *Attempts at resuscitation after cardiac arrest* - This category includes patients for whom **resuscitation efforts** were initiated following cardiac arrest but were ultimately unsuccessful. - Organ donation in this context requires assessment of the impact of resuscitation on **organ perfusion** and viability. *Cardiac arrest following brain death declaration* - This scenario describes donation after **neurological determination of death** (brain death), not cardiac death. - In brain death, the heart may still be beating with full circulatory support, and organ procurement occurs while **circulation is maintained**.
Question 4: The hypersensitivity reaction involved in the hyperacute rejection of a renal transplant is:
- A. Type I
- B. Type III
- C. Type IV
- D. Type II (Correct Answer)
Explanation: ***Type II*** - Hyperacute rejection is primarily mediated by **antibody-mediated mechanisms**, indicative of Type II hypersensitivity [2]. - It involves pre-existing **IgG antibodies** that react against donor renal graft antigen, leading to rapid graft destruction [1]. *Type I* - Type I hypersensitivity is associated with **allergic reactions** involving **IgE antibodies**, not relevant to transplant rejection [2]. - Typically involves conditions like **anaphylaxis** or **asthma**, which are unrelated to hyperacute rejection scenarios. *Type IV* - Type IV hypersensitivity is cell-mediated and typically manifests as **delayed-type hypersensitivity**, not acute rejection. - It involves **T cells** and does not play a role in the immediate immune response seen in hyperacute rejection. *Type III* - Type III hypersensitivity involves the formation of immune complexes, leading to conditions like **serum sickness**, not hyperacute rejection. - This type of reaction is usually more relevant in **chronic inflammatory conditions** rather than immediate transplant rejections. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 241-242. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 208-210.
Question 5: Feature NOT seen in acute rejection of transplanted kidney?
- A. Tubulitis
- B. Wire-loop lesions (Correct Answer)
- C. Endothelialitis
- D. Interstitial infiltrate
Explanation: ***Wire-loop lesions*** - **Wire-loop lesions** are characteristic histological findings of diffuse proliferative glomerulonephritis, typically seen in **lupus nephritis (Class III or IV)** [3], and are not associated with acute kidney transplant rejection. - These lesions represent pronounced subendothelial immune complex deposition, leading to thickening and stiffness of the capillary walls [4]. *Tubulitis* - **Tubulitis**, defined as inflammatory cells (lymphocytes) infiltrating the tubular epithelium, is a **hallmark pathological feature of acute T-cell mediated rejection** in kidney allografts [1]. - Its presence indicates a significant immunologic attack on the renal tubules. *Endothelialitis* - **Endothelialitis**, or inflammation of the endothelial cells lining renal vessels, especially venules and arteries, is another key histological feature of **acute rejection**, particularly severe forms of T-cell mediated and antibody-mediated rejection [2], [1]. - It often correlates with the severity of rejection and can lead to vascular damage. *Interstitial infiltrate* - A prominent **interstitial infiltrate**, primarily composed of lymphocytes, macrophages, and plasma cells, is a fundamental characteristic of **acute cellular rejection** in transplanted kidneys [1]. - This inflammatory infiltrate surrounds the tubules and small vessels, indicating an immune attack on the allograft. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 241-242. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 546-549. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 230-232. [4] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 528-529.
Question 6: Which is the most common causative organism involved in infections after kidney transplantation?
- A. Klebsiella
- B. Epstein Barr virus
- C. Cytomegalovirus (Correct Answer)
- D. Herpes simplex virus
Explanation: ***Cytomegalovirus*** - **Cytomegalovirus (CMV)** is the most common opportunistic infection after kidney transplantation, occurring in **50-80%** of transplant recipients. - CMV infection or reactivation typically occurs **1-6 months post-transplant** due to intense **immunosuppression** required to prevent graft rejection. - Highest risk is in **donor-positive/recipient-negative (D+/R-)** serostatus, but reactivation can occur in seropositive recipients. - CMV can cause **fever, leukopenia, graft dysfunction**, and invasive disease affecting multiple organ systems. *Klebsiella* - While *Klebsiella* can cause serious bacterial infections, particularly **urinary tract infections** and **pneumonia** in transplant patients, it is not the most common overall causative organism for post-transplant infections. - Bacterial infections like *Klebsiella* are often related to indwelling catheters or surgical sites but are less ubiquitous than viral reactivations in immunosuppressed patients. *Epstein Barr virus* - **Epstein-Barr Virus (EBV)** is another significant viral pathogen in transplant recipients, primarily associated with **post-transplant lymphoproliferative disorder (PTLD)**. - While important, EBV infection or reactivation is not as universally prevalent or as frequently symptomatic as CMV in the post-transplant period. *Herpes simplex virus* - **Herpes simplex virus (HSV)** can cause infections in transplant patients, leading to **mucocutaneous lesions** and occasionally disseminated disease. - HSV infections are generally less severe and less common than CMV, which can affect multiple organ systems and has a higher morbidity burden in this population.
Question 7: 'Triphasic waveform' on colour Doppler is of
- A. Portal vein
- B. Hepatic artery
- C. Hepatic vein (Correct Answer)
- D. All of the options
Explanation: ***Hepatic vein*** - A normal hepatic vein Doppler waveform is **triphasic**, showing two antegrade (towards the heart) waves corresponding to **ventricular systole (S wave)** and **diastole (D wave)**, and one small retrograde (away from the heart) wave corresponding to **atrial contraction (a wave)**. - This triphasic pattern reflects the cyclic pressure changes in the right atrium and is crucial for assessing **right heart function** and conditions affecting hepatic venous outflow. *Portal vein* - The portal vein typically exhibits a **monophasic waveform** with continuous, low-velocity, hepatopetal (towards the liver) flow, often with slight undulations due to respiration. - The absence of a triphasic pattern differentiates it from the hepatic veins, as its flow is driven by pressure differences from the mesenteric circulation, not directly by cardiac cycles. *Hepatic artery* - The hepatic artery demonstrates a **high-resistive, biphasic waveform** with a sharp systolic peak and continuous diastolic flow, reflecting its essential role in supplying oxygenated blood to the liver parenchyma. - It does not show a triphasic pattern, which is characteristic of venous structures influenced by right atrial pressures. *All of the options* - This option is incorrect because only the **hepatic veins** typically display a triphasic waveform; the portal vein and hepatic artery have distinct, different waveform patterns. - Each vessel's unique flow pattern is indicative of its specific physiological role and anatomical connection to the cardiac cycle.
Question 8: Which of the following is least likely in PDA?
- A. CO, wash out (Correct Answer)
- B. Bounding pulse
- C. Pulmonary hemorrhage
- D. Necrotizing enterocolitis
Explanation: ***CO₂ washout*** - **CO₂ washout** is not a recognized clinical complication or standard finding associated with PDA - While PDA causes **pulmonary overcirculation**, this does not translate into a clinically significant "CO₂ washout" phenomenon - The other options represent well-established associations with hemodynamically significant PDA - This is the **least likely** finding in PDA *Bounding pulse* - **Classic finding** in PDA due to left-to-right shunt from aorta to pulmonary artery - Results in **wide pulse pressure** as diastolic pressure drops (blood "runs off" into pulmonary circulation) - Creates characteristic **water-hammer** or **bounding peripheral pulses** *Pulmonary hemorrhage* - Well-recognized complication of hemodynamically significant PDA, especially in **premature infants** - **Increased pulmonary blood flow and pressure** from left-to-right shunt leads to pulmonary edema and capillary damage - Fragile pulmonary vasculature in preterm infants predisposes to **hemorrhage** *Necrotizing enterocolitis* - **Significant association** between PDA and NEC in premature infants - Mechanism: **Diastolic steal** phenomenon causes mesenteric hypoperfusion - The left-to-right shunt diverts blood flow during diastole, leading to **gut ischemia** - PDA is a recognized **risk factor** for NEC development
Question 9: Aetiology of Dressler Syndrome is
- A. Autoimmune (Correct Answer)
- B. Toxin mediated
- C. Viral infection
- D. Idiopathic cause
Explanation: ***Autoimmune*** - Dressler syndrome is a form of **pericarditis** that occurs several days to weeks after myocardial injury (e.g., myocardial infarction, cardiac surgery, trauma). [3] - It is considered an **autoimmune phenomenon** where the body's immune system attacks damaged cardiac tissue. [1] *Viral infection* - While viral infections can cause general pericarditis, Dressler syndrome specifically refers to **post-cardiac injury** inflammation, not direct viral involvement. [2], [3] - Viral pericarditis typically has a more acute presentation without a preceding cardiac event. [2] *Toxin mediated* - There is no evidence to suggest that Dressler syndrome is caused by **toxins** or toxic substances. - The pathogenesis is linked to an immune response to damaged myocardial cells. *Idiopathic cause* - While some forms of pericarditis are idiopathic, Dressler syndrome has a clear **triggering event** (cardiac injury) and a well-understood autoimmune mechanism. [3] - Therefore, it is not classified as idiopathic. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 214-215. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 581-582. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 297-298.
Question 10: An athlete collapsed and expired while playing school basketball. Histology of the cardiac specimen is most likely to indicate which of the following conditions?
- A. Dilated cardiomyopathy (DCM)
- B. Restrictive cardiomyopathy (RCM)
- C. Arrhythmogenic right ventricular dysplasia (ARVD)
- D. Hypertrophic cardiomyopathy (HCM) (Correct Answer)
Explanation: ***Hypertrophic cardiomyopathy (HCM)*** - The image shows **myocardial disarray and hypertrophy**, characterized by haphazardly arranged and abnormally branched cardiac muscle cells with large, irregular nuclei, which is a classic histologic finding in HCM [1]. - HCM is the most common cause of **sudden cardiac death in young athletes**, often during exertion, due to ventricular arrhythmias arising from the disarrayed myocardium [1]. *Dilated cardiomyopathy (DCM)* - Histology for DCM typically shows **myocyte atrophy**, thinning of the ventricular walls, and interstitial fibrosis, not the marked disarray and hypertrophy seen here [3]. - DCM leads to **progressive cardiac enlargement and systolic dysfunction**, and while it can cause sudden death, it is less common in athletes than HCM [4]. *Restrictive cardiomyopathy (RCM)* - RCM is characterized by **stiff, non-compliant ventricles** with impaired diastolic filling, often due to conditions like amyloidosis or sarcoidosis, showing interstitial infiltration or fibrosis. - The image does not show evidence of significant **interstitial infiltration or severe fibrosis** characteristic of RCM; instead, it highlights myocyte pathology. *Arrhythmogenic right ventricular dysplasia (ARVD)* - ARVD is characterized by the **replacement of right ventricular myocardium with fibrofatty tissue**, which would be evident histologically as fat and fibrous infiltration [2]. - While ARVD can cause sudden death in athletes, the displayed image primarily shows **myocyte hypertrophy and disarray**, not extensive fibrofatty replacement [2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 577-578. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 576-577. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, p. 576. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 559-560.
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