Renal Transplantation Pathology — MCQs
A patient presented with edema, oliguria and frothy urine. He has no past history of similar complaints. On examination, his urine was positive for 3+ proteinuria, no RBCs/WBCs and no casts. His serum albumin was 2.5 gm/L and serum creatinine was 0.5 mg/dL. The most likely diagnosis is:
Which of the following statements regarding rejection of solid organ transplants is true?
After 4 months of renal transplantation, a patient is likely to develop which infection?
Which of the following is true regarding extended criteria donors for liver transplantation?
Deposition of Anti ds DNA Ab in kidney, skin, choroid plexus and joints is seen in:
Which of the following statements about transplant rejection reactions is false:
What is the number of antigens typically evaluated in comprehensive HLA matching for organ transplantation?
Most common presentation of Wilms' tumor?
All of the following are features of Goodpasture syndrome, except for which of the following?
Investigation of choice for confirming Henoch Schönlein Purpura is
Renal Transplantation Pathology Indian Medical PG Practice Questions and MCQs
Question 1: A patient presented with edema, oliguria and frothy urine. He has no past history of similar complaints. On examination, his urine was positive for 3+ proteinuria, no RBCs/WBCs and no casts. His serum albumin was 2.5 gm/L and serum creatinine was 0.5 mg/dL. The most likely diagnosis is:
- A. Interstitial nephritis
- B. Minimal change disease (Correct Answer)
- C. Membranous nephropathy
- D. IgA nephropathy
Explanation: ***Minimal change disease*** - The classic presentation of **edema**, **oliguria**, and **frothy urine** (due to heavy proteinuria), along with **isolated proteinuria** (no RBCs/WBCs/casts) and **low serum albumin**, points to **nephrotic syndrome** [1]. **Minimal change disease** is the most common cause of nephrotic syndrome in children and a significant cause in adults, often presenting acutely without prior history [1]. - The **normal serum creatinine** (0.5 mg/dL) indicates preserved renal function, which is typical in early minimal change disease before significant complications arise [2]. *Interstitial nephritis* - This condition is characterized by **inflammation of the renal interstitium**, often leading to **acute kidney injury** with an elevation in serum creatinine. It's typically associated with a history of **drug exposure** or **systemic autoimmune diseases**. - Urinalysis usually reveals **white blood cells**, **eosinophils**, and sometimes **WBC casts**, which are absent in this patient. *Membranous nephropathy* - While it causes **nephrotic syndrome** with heavy proteinuria, it often presents more **insidiously** and is more common in older adults. - Urinalysis typically shows **microscopic hematuria** in a significant proportion of cases, secondary to glomerular injury, which is not noted here. *IgA nephropathy* - This is a common cause of **glomerulonephritis**, primarily characterized by **recurrent macroscopic or microscopic hematuria**, often following an upper respiratory or gastrointestinal infection. - While proteinuria can occur, it's typically **not in the nephrotic range** (3+ proteinuria suggests heavy proteinuria), and prominent edema is usually absent unless severe renal failure has developed.
Question 2: Which of the following statements regarding rejection of solid organ transplants is true?
- A. Most immunosuppressive medications are used to prevent chronic rejection
- B. The major cause of graft failure is acute rejection
- C. Liver transplants are especially susceptible to hyperacute rejection
- D. Hyperacute rejection begins in the operating room with reperfusion of the transplanted organ (Correct Answer)
Explanation: ***Hyperacute rejection begins in the operating room with reperfusion of the transplanted organ*** - **Hyperacute rejection** is a rapidly-occurring immune response that starts almost immediately after the transplanted organ is re-vascularized, often while the patient is still in the operating room [1]. - This type of rejection is mediated by **pre-formed antibodies** (e.g., ABO blood group antibodies or anti-HLA antibodies) in the recipient's circulation that bind to antigens on the donor organ's endothelium, leading to massive thrombosis and organ destruction [1]. *Most immunosuppressive medications are used to prevent chronic rejection* - While immunosuppressants play a role in mitigating **chronic rejection**, their primary and most effective targets are **acute rejection episodes** and the initial prevention of organ rejection [2]. - **Chronic rejection** is often a more complex process involving both immune and non-immune factors, and current immunosuppressive regimens are less effective at completely preventing or reversing it compared to acute rejection. *The major cause of graft failure is acute rejection* - In the long term, **chronic rejection** (or chronic allograft dysfunction) is the leading cause of late graft loss, rather than acute rejection. - With advancements in immunosuppression, **acute rejection rates** have significantly decreased, making chronic issues and non-immune factors more prominent in overall graft failure. *Liver transplants are especially susceptible to hyperacute rejection* - **Liver transplants** are notably more tolerant to ABO and HLA mismatches compared to other solid organ transplants (like kidney or heart). - This relative immunotolerance means that **hyperacute rejection** is far less common in liver transplantation. **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. (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: After 4 months of renal transplantation, a patient is likely to develop which infection?
- A. EBV
- B. CMV (Correct Answer)
- C. Candida
- D. Histoplasma
Explanation: ***CMV*** - **Cytomegalovirus (CMV)** infection is very common in solid organ transplant recipients, particularly in the period between **1 to 6 months post-transplant**, known as the **intermediate period** [1]. - This timing is due to the cumulative effect of **immunosuppression** compromising the patient's ability to control latent viral shedding or newly acquired infection. *EBV* - **Epstein-Barr virus (EBV)** infection is also common in transplant recipients, but it is more significantly associated with the development of **post-transplant lymphoproliferative disorder (PTLD)**, rather than being the *most likely* general infection at 4 months [2], [3]. - While EBV can occur, CMV is typically more prevalent as a symptomatic viral infection in the intermediate post-transplant period [1]. *Candida* - **Candida** infections (fungal) are more common in the **early post-transplant period** (within the first month), often associated with surgical complications, indwelling catheters, or broad-spectrum antibiotic use [1]. - While possible, it is less likely to be the *most common* infection at 4 months compared to CMV. *Histoplasma* - **Histoplasma** infections are a **systemic fungal infection** that is typically seen in transplant patients who have been exposed to endemic areas. - It is not a common opportunistic infection universally seen in transplant recipients at 4 months post-transplant but rather depends on geographical exposure and specific risk factors.
Question 4: Which of the following is true regarding extended criteria donors for liver transplantation?
- A. Donors with well-controlled diabetes mellitus
- B. Hepatitis C antibody positive donors
- C. Donors with significant uncontrolled comorbidities
- D. Donors aged >60 years with no significant comorbidities (Correct Answer)
Explanation: ***Donors aged >60 years with no significant comorbidities*** - **Advanced donor age** is a key characteristic of an extended criteria donor (ECD), especially when coupled with other factors like **ischemic time** or comorbidities. - While age alone might not prohibit donation, it puts the donor liver into the ECD category, requiring careful recipient selection and possibly increasing the risk of **post-transplant complications**. *Donors with well-controlled diabetes mellitus* - **Well-controlled diabetes mellitus** in a donor does not automatically classify them as an extended criteria donor, if there are no other significant associated comorbidities or organ damage. - The focus is generally on signs of significant end-organ damage or poorly controlled disease that could impact graft function. *Hepatitis C antibody positive donors* - **Hepatitis C antibody positive donors** are traditionally considered extended criteria donors and remain classified as such. - However, with the advent of highly effective **direct-acting antiviral (DAA) therapies**, HCV-positive organs can now be safely transplanted into both HCV-positive and HCV-negative recipients with excellent outcomes. - While still technically ECD, the clinical significance has diminished significantly with modern treatment availability, making **donor age >60 years** the more universally recognized ECD criterion in current practice. *Donors with significant uncontrolled comorbidities* - **Significant uncontrolled comorbidities** would generally render a donor **unsuitable for donation**, rather than classify them as an extended criteria donor. - Extended criteria typically refer to factors that increase risk but are still acceptable under specific circumstances, whereas uncontrolled comorbidities often pose too high a risk for successful transplantation.
Question 5: Deposition of Anti ds DNA Ab in kidney, skin, choroid plexus and joints is seen in:
- A. Good pasture
- B. Raynauds disease
- C. SLE (Correct Answer)
- D. Scleroderma
Explanation: ### SLE - **Anti-dsDNA antibodies** are highly specific for **Systemic Lupus Erythematosus (SLE)** and are involved in the pathophysiology of organ damage in this autoimmune disease [2]. - The deposition of these antibodies and immune complexes in various tissues like the **kidney (lupus nephritis)**, **skin (malar rash, discoid lupus)**, **choroid plexus (neuropsychiatric lupus)**, and **joints (arthralgia/arthritis)** is characteristic of SLE [1]. ### Good pasture - Goodpasture syndrome is characterized by **anti-glomerular basement membrane (anti-GBM) antibodies** that primarily target the **kidneys** and **lungs**. - It does not involve the deposition of anti-dsDNA antibodies or affect the skin, choroid plexus, or joints in the same manner as SLE. ### Raynauds disease - Raynaud's disease is a **vasospastic disorder** affecting small arteries, typically in the fingers and toes, leading to episodic color changes (white, blue, red). - It is not an autoimmune disease characterized by antibody deposition in organs, although it can be a symptom of underlying connective tissue diseases like SLE [1]. ### Scleroderma - Scleroderma (systemic sclerosis) is an autoimmune disease characterized by **fibrosis** of the skin and internal organs, and **vascular dysfunction**. - While it can involve **autoantibodies (e.g., anti-topoisomerase I, anti-centromere)**, it is not primarily associated with anti-dsDNA antibody deposition or the specific pattern of organ involvement seen in SLE [2].
Question 6: 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 7: What is the number of antigens typically evaluated in comprehensive HLA matching for organ transplantation?
- A. 10 (Correct Answer)
- B. 4
- C. 16
- D. 22
Explanation: ***10*** - The **number of criteria for HLA matching** in organ transplantation is typically 10, consisting of 6 class I and 4 class II antigens. - Proper HLA matching is critical for minimizing the risk of **graft rejection** and ensuring **recipient compatibility** [1]. *16* - While there are various HLA antigens, a total of **16** criteria is not a standard number used for matching purposes. - This number may include other factors but does not represent the core criteria for **HLA matching**. *4* - HLA matching involves more than **4 criteria**, inadequate for reliable transplantation outcomes. - This number does not encompass the essential **class I and class II antigens** that are necessary for effective matching. *22* - A total of **22 criteria** exceeds the conventional standard for HLA matching, which is not practical or necessary. - This figure may relate to overall HLA typing but is not applicable for the matching process itself. **References:** [1] 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. 179-180.
Question 8: Most common presentation of Wilms' tumor?
- A. Asymptomatic abdominal mass (Correct Answer)
- B. Abdominal pain
- C. Headache
- D. Hematuria
Explanation: ***Asymptomatic abdominal mass*** - **Wilms' tumor** is often discovered incidentally during routine examination or when a parent notices an **enlarged abdomen** or a lump. - The tumor can grow quite large before causing any noticeable symptoms beyond the mass itself, indicating its **asymptomatic nature** initially. *Abdominal pain* - While some children with Wilms' tumor may experience abdominal pain, it is less common as the primary presenting symptom compared to the discovery of a visible or palpable **mass**. - Pain usually occurs if the tumor is particularly large, ruptures, or causes secondary complications like **bowel obstruction**. *Headache* - Headache is **not a typical presenting symptom** of Wilms' tumor, as it is a renal tumor and does not directly affect the central nervous system in its early stages. - Headaches might rarely occur in very advanced cases with **metastatic disease** to the brain, but this is not the most common initial presentation. *Hematuria* - Microscopic or gross **hematuria** can occur in children with Wilms' tumor due to irritation or invasion of the renal collecting system. - However, it is reported in a minority of cases (around 20-30%) and is **less frequent** as the initial primary complaint compared to the discovery of an abdominal mass.
Question 9: All of the following are features of Goodpasture syndrome, except for which of the following?
- A. Hemoptysis
- B. Antibody to alpha-3 chain of type IV collagen (COL4A3)
- C. Subendothelial IgG deposits in renal biopsy (Correct Answer)
- D. Linear IgG deposits on the glomerular basement membrane
Explanation: ***Subendothelial IgG deposits in renal biopsy*** - Goodpasture syndrome is characterized by the presence of **anti-glomerular basement membrane antibodies** [1], not subendothelial IgG deposits. - Renal biopsy typically shows a **linear pattern** of IgG deposition along the glomerular basement membrane [2], rather than subendothelial deposits. *Pulmonary haemorrhage* - A hallmark of Goodpasture syndrome [1], resulting from the antibodies targeting the lungs, leading to **alveolar damage**. - Patients often present with **hemoptysis** and signs of respiratory failure due to pulmonary complications [1]. *Glomerular basement membrane is involved* - This syndrome specifically targets the **glomerular basement membrane**, causing **rapidly progressive glomerulonephritis (RPGN)** [1]. - The involvement of the glomerular basement membrane is a significant feature of Goodpasture syndrome. *Antibody to alpha-3 chain of type IV collagen (COL4A3)* - Goodpasture syndrome is associated with antibodies against the **alpha-3 chain of type IV collagen**, crucial for the pathogenesis. - These antibodies lead to damage in both the **renal and pulmonary** systems due to the shared type IV collagen in the basement membranes. Recovery of renal function may follow early intensive plasmapheresis combined with steroids and cytotoxic agents [3]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 537-538. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 526-527. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 918-919.
Question 10: Investigation of choice for confirming Henoch Schönlein Purpura is
- A. Serum IgA levels
- B. CRP levels
- C. DTPA
- D. Renal Biopsy (Correct Answer)
Explanation: ***Renal Biopsy*** - **Biopsy (renal or skin)** showing **IgA deposition** is the **confirmatory investigation** for Henoch-Schönlein Purpura (HSP) when histological confirmation is needed [1]. - **Renal biopsy** demonstrates characteristic **IgA-dominant immune deposits** in the mesangium and glomerular capillaries, along with **mesangial proliferation** [1]. - While HSP is primarily a **clinical diagnosis** based on palpable purpura, age < 20 years, abdominal pain, and renal involvement, biopsy provides **definitive confirmation** in atypical presentations or when diagnosis is uncertain. - Immunofluorescence showing **IgA deposition** is the pathognomonic finding [1]. *Serum IgA levels* - Serum IgA levels may be elevated in approximately **50% of HSP cases**, but this is **neither sensitive nor specific**. - **Normal serum IgA does NOT exclude HSP**, making it unreliable as a confirmatory test. - Elevated IgA can occur in many other conditions (IgA nephropathy without vasculitis, liver disease, infections). - Provides only supportive evidence, not confirmation. *CRP levels* - **C-reactive protein (CRP)** is a **non-specific inflammatory marker** that may be elevated in HSP. - Cannot distinguish HSP from other inflammatory or infectious conditions. - Has no role in confirming the diagnosis. *DTPA* - **DTPA scan** assesses **renal perfusion and function** but does not provide diagnostic information about the underlying pathology. - Cannot detect the characteristic **IgA-mediated vasculitis** of HSP. - Not useful for confirming the diagnosis. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 526-527.
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