Transplant Surgery Practice Questions

Q: All of the following are true about the history of transplantation except:

First successful intestinal transplantation by Hardy. ***First successful intestinal transplantation by Hardy*** - The **first successful intestinal transplantation** was **NOT performed by Hardy**. - **Hardy** is famous for the **first human lung transplant** in **1963** and the **first heart xenotransplant** (chimpanzee to human) in **1964**. - **Intestinal transplantation** had its first long-term success in the late **1980s** (notably by **Starzl** and others after the introduction of cyclosporine). - This statement is **FALSE**, making it the correct answer to this "EXCEPT" question. *First pancreas transplantation by Kelly & Lillhei* - The **first successful human pancreas transplant** was indeed performed by **William Kelly** and **Richard Lillehei** at the University of Minnesota in **1966**. - This was a **simultaneous pancreas-kidney transplant** for a patient with diabetes and renal failure. - This statement is **TRUE**. *First lung transplantation by Fritz Derom* - This is **contextually TRUE** when referring to the **first successful lung transplant with meaningful survival**. - **James Hardy** performed the **first human lung transplant** in **1963**, but the patient survived only **18 days**. - **Fritz Derom** (Belgium) performed a lung transplant in **1968** with the patient surviving **10 months**, representing the first case with significant survival. - In transplant history, Derom is often credited as this represented a more meaningful milestone. - This statement is generally considered **TRUE**. *First heart & lung transplantation by Reitz & Shumway* - **Bruce Reitz** and his team at Stanford University, working under **Norman Shumway**, performed the **first successful combined heart-lung transplant** in **1981**. - The patient, Mary Gohlke, survived for **5 years** post-transplant. - This statement is **TRUE**.

Q: Transplantation of liver is contraindicated in:

Metastasis to liver. ***Metastasis to liver*** - The presence of **metastasis to the liver** from another primary cancer is a general contraindication for liver transplantation. - This is because the underlying malignancy is systemic, and transplantation would not cure the cancer, with high risk of **disease recurrence** in the transplanted organ or elsewhere. *Renal failure* - **Renal failure** alone is not an absolute contraindication for liver transplantation; patients with **hepatorenal syndrome** or chronic kidney disease can undergo combined liver-kidney transplantation. - The decision depends on the reversibility of renal failure and the overall clinical picture. *Acute fulminant liver disease* - **Acute fulminant liver disease** is a common and often urgent **indication** for liver transplantation, not a contraindication. - Transplantation is life-saving in these cases when medical management fails due to rapid deterioration and high mortality. *Viral hepatitis* - **Viral hepatitis** (e.g., hepatitis C, hepatitis B) is a common cause of end-stage liver disease and is a leading **indication** for liver transplantation. - With modern antiviral therapies, patients can often receive a transplant and manage the viral recurrence post-transplant.

Q: A woman receives an organ transplant from her sister who is an identical twin. What type of graft is it?

Isograft. ***Isograft*** - An isograft (or syngeneic graft) refers to tissue transplanted between **genetically identical** individuals, such as identical twins. - In such cases, there is no **immune rejection** because the donor and recipient share the exact same genetic makeup. *Xenograft* - A xenograft involves transplanting tissue or organs from one **species to another**, for example, from a pig to a human. - These grafts typically face strong and immediate **immune rejection** due to significant genetic differences. *Autograft* - An autograft is a transplant of tissue from one part of an individual's body to **another part of the same individual**. - Examples include a **skin graft** from a thigh to a burn on the arm, and there is no risk of immune rejection. *Allograft* - An allograft involves transplanting tissue or organs between **genetically non-identical individuals of the same species**, such as a transplant from one human to another unrelated human. - These grafts typically require **immunosuppressive drugs** to prevent rejection due to genetic differences.

Q: Auxiliary orthotopic liver transplant is indicated for

Acute fulminant liver failure for any cause. ***Acute fulminant liver failure for any cause*** - **Auxiliary orthotopic liver transplant (AOLT)** is primarily indicated in acute fulminant liver failure because it allows for the potential regeneration of the native liver while providing immediate liver support. - This technique preserves the **native liver**, which can recover and take over function if the underlying cause is reversible, allowing for eventual withdrawal of immunosuppression. *Metabolic liver disease* - For **metabolic liver diseases**, the primary goal is often to replace the diseased liver with a healthy one to correct the metabolic defect, making **orthotopic liver transplantation (OLT)** the standard. - In most metabolic liver diseases, the native liver is permanently dysfunctional and not expected to recover significant function, rendering AOLT less beneficial. *Drug induced hepatic failure* - While drug-induced hepatic failure can be a form of acute liver failure, the scope of the option "Acute fulminant liver failure for any cause" is broader and more accurately encapsulates the primary indication for AOLT. - If the native liver has sustained irreversible damage from drugs, a full **orthotopic liver transplant** would be more appropriate than an auxiliary approach. *As a standby procedure until finding a suitable donor* - AOLT is a definitive treatment strategy aimed at liver support and potential native liver recovery, not a temporary measure to bridge to another transplant or donor. - The concept of a "standby procedure" until a donor is found typically refers to urgent **orthotopic liver transplantation** listings or temporary support like extracorporeal devices, not AOLT.

Q: Which of the following is true regarding extended criteria donors for liver transplantation?

Donors aged >60 years with no significant comorbidities. ***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.

Q: Renal transplantation is most commonly done in?

Chronic glomerulonephritis. ***Chronic glomerulonephritis*** - **Chronic glomerulonephritis** is one of the **major causes of end-stage renal disease (ESRD)** requiring renal transplantation, accounting for approximately **10-15% of transplants**. - It leads to progressive destruction of the glomeruli, resulting in irreversible loss of kidney function. - **Note:** In current practice, diabetic nephropathy and hypertensive nephrosclerosis are more common causes of ESRD, but among the options listed, chronic glomerulonephritis is the most significant indication for transplantation. *Horseshoe kidney* - A **horseshoe kidney** is a **congenital anatomical anomaly** where the kidneys are fused, usually at their lower poles. - While it can increase the risk of certain renal conditions like stones, infections, or hydronephrosis, it is **not a primary cause of ESRD** requiring transplantation. - Horseshoe kidney itself is not an indication for transplantation. *Bilateral staghorn calculus* - **Bilateral staghorn calculi** are large, branching kidney stones that can fill the renal pelvis and calyces. - While they can cause significant kidney damage, infection, and obstruction, they are **managed surgically** (percutaneous nephrolithotomy, ureteroscopy) and **rarely progress to ESRD** requiring transplantation if treated appropriately. - They represent a treatable condition rather than a primary transplant indication. *Oxalosis* - **Primary hyperoxaluria (oxalosis)** is a **rare genetic disorder** characterized by excessive oxalate production and deposition in kidneys and other organs. - Although it can lead to ESRD and requires combined **liver-kidney transplantation**, it is a **much less common** indication compared to chronic glomerulonephritis. - Accounts for <1% of transplant cases.

Q: What is safe maximum time for storage of heart?

6 hours. ***6 hours*** - The **ischemic time** for a donor heart before transplantation is ideally kept under **4-6 hours** to minimize damage and ensure successful engraftment. - **6 hours represents the absolute maximum** safe cold ischemic time, though shorter durations (closer to 4 hours) are associated with better outcomes. - Prolonged cold ischemic time significantly increases the risk of **primary graft dysfunction** and reduces long-term survival. *2 hours* - While a shorter ischemic time is always preferable, 2 hours is often not logistically feasible given the complexities of **organ retrieval** and **transportation**. - Many heart transplants are successfully performed with an ischemic time longer than 2 hours without major complications. - This would be an ideal but impractical limit in most real-world scenarios. *4 hours* - Although **4 hours** is the recommended optimal limit and many guidelines suggest this as the target, the question asks for the **maximum** safe time. - Most centers aim for under 4 hours, but can extend to 6 hours with acceptable outcomes for carefully selected donors and recipients. - The precise limit depends on various factors including the **donor's age and health**, and the preservation solution used. *8 hours* - An ischemic time of **8 hours** for a donor heart is generally considered too long and would result in a very high risk of **irreversible myocardial damage** and poor graft function. - This duration would lead to significantly increased rates of **primary graft failure** and mortality. - Beyond 6 hours, the risk of complications increases exponentially.

Q: Graft Survival in first 48 hours depends on

Plasma imbibition. ***Plasma imbibition*** - In the initial 24-48 hours post-grafting, the graft survives primarily through **plasma imbibition**, absorbing nutrients and oxygen directly from the recipient bed fluids without established blood vessels. - This process is crucial for the survival of superficial cells until revascularization begins. *Amount of Saline in graft* - While initial hydration of the graft with saline is important during the procedure, it does not sustain graft viability for the entire 48-hour period. - The saline provides temporary turgor and moisture but doesn't offer the continuous nutrient supply required for cell survival. *Connection between donor and recipient capillaries* - The formation of direct capillary connections, known as **inosculation**, typically starts occurring after 24-48 hours, not within the first 48 hours for the primary survival mechanism. - This process is part of sustained revascularization and not the immediate survival mechanism. *Ingrowth of capillaries in donor tissue* - The actual ingrowth of new capillaries (neovascularization) into the graft tissue is a more delayed process, starting after the initial several days and continuing over weeks. - This is a long-term revascularization process, not the mechanism ensuring immediate survival.

Q: Which animal's heart has been used for transplantation in humans?

Pig. ***Pig*** - **Pig hearts** and heart valves have been successfully used in **xenotransplantation** due to their physiological similarities to human hearts. - Recent advances in **genetic modification** have reduced the risk of rejection, making pig organs viable for human transplantation. *Rabbit* - Rabbit hearts are significantly smaller and anatomically distinct from human hearts, making them unsuitable for whole heart transplantation. - While rabbits are used in research, their organs lack the necessary size and physiological compatibility for human organ replacement. *Sheep* - Sheep hearts have been used in some research for cardiovascular device testing, but not for whole organ transplantation in humans. - Their heart size and physiology are not as closely matched to humans as pigs for xenotransplantation purposes. *Horse* - Horse hearts are considerably larger and structurally different from human hearts, posing significant anatomical and physiological challenges for transplantation. - There is no clinical or research precedent for horse heart transplantation into humans.

Q: All are indications of liver transplantation except:

Hepatic adenomas. ***Hepatic adenomas*** - **Hepatic adenomas** are benign liver tumors that generally do not require liver transplantation unless they are **very large**, symptomatic, or show signs of **malignant transformation** or rupture, which are rare indications compared to other severe liver diseases. - Management usually involves **surgical resection** or close monitoring, not transplantation. *Primary sclerosing cholangitis* - **Primary sclerosing cholangitis (PSC)** is a chronic cholestatic liver disease that often progresses to **cirrhosis** and liver failure, making it a common indication for liver transplantation. - It also carries an increased risk of **cholangiocarcinoma**, an indication for transplant if diagnosed early under specific criteria. *Fulminant hepatitis* - **Fulminant hepatitis** (acute liver failure) involves severe, rapid onset liver dysfunction with **encephalopathy** and coagulopathy in individuals without pre-existing liver disease. - It is a **life-threatening condition** that often necessitates urgent liver transplantation. *Alcoholic cirrhosis* - **Alcoholic cirrhosis** is a leading cause of end-stage liver disease and is a common indication for liver transplantation, often after a period of **abstinence** from alcohol. - Transplantation is considered when the liver damage is irreversible and life-threatening, and the patient meets specific criteria, including a commitment to sobriety.

Question 1

All of the following are true about the history of transplantation except:

Accepted Answer

First successful intestinal transplantation by Hardy

Answer

First pancreas transplantation by Kelly & Lillhei

Answer

First lung transplantation by Fritz Derom

Answer

First heart & lung transplantation by Reitz & Shumway

Question 2

Transplantation of liver is contraindicated in:

Accepted Answer

Metastasis to liver

Answer

Renal failure

Answer

Acute fulminant liver disease

Answer

Viral hepatitis

Question 3

A woman receives an organ transplant from her sister who is an identical twin. What type of graft is it?

Accepted Answer

Isograft

Answer

Xenograft

Answer

Autograft

Answer

Allograft

Question 4

Auxiliary orthotopic liver transplant is indicated for

Accepted Answer

Acute fulminant liver failure for any cause

Answer

Metabolic liver disease

Answer

Drug induced hepatic failure

Answer

As a standby procedure until finding a suitable donor

Question 5

Which of the following is true regarding extended criteria donors for liver transplantation?

Accepted Answer

Donors aged >60 years with no significant comorbidities

Answer

Donors with well-controlled diabetes mellitus

Answer

Hepatitis C antibody positive donors

Answer

Donors with significant uncontrolled comorbidities

Question 6

Renal transplantation is most commonly done in?

Accepted Answer

Chronic glomerulonephritis

Answer

Horseshoe kidney

Answer

Bilateral staghorn calculus

Answer

Oxalosis

Question 7

What is safe maximum time for storage of heart?

Accepted Answer

6 hours

Answer

2 hours

Answer

4 hours

Answer

8 hours

Question 8

Graft Survival in first 48 hours depends on

Accepted Answer

Plasma imbibition

Answer

Amount of Saline in graft

Answer

Connection between donor and recipient capillaries

Answer

Ingrowth of capillaries in donor tissue

Question 9

Which animal's heart has been used for transplantation in humans?

Accepted Answer

Pig

Answer

Rabbit

Answer

Sheep

Answer

Horse

Question 10

All are indications of liver transplantation except:

Accepted Answer

Hepatic adenomas

Answer

Primary sclerosing cholangitis

Answer

Fulminant hepatitis

Answer

Alcoholic cirrhosis

Answer

Primary biliary cirrhosis

Transplant Surgery — MCQs

Transplant Surgery — MCQs

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