Transplant Surgery Practice Questions

Q: Which of the following is an absolute contraindication to liver transplantation?

AIDS. **Explanation:** In liver transplantation, contraindications are categorized into **absolute** (conditions where the risk of surgery or post-transplant failure is prohibitively high) and **relative** (conditions that increase risk but can be managed). **Why AIDS is the Correct Answer:** Historically, **AIDS** (defined by low CD4 counts and opportunistic infections) is considered an **absolute contraindication**. The primary concern is that the mandatory post-transplant immunosuppression will further deplete the immune system, leading to uncontrollable opportunistic infections and poor survival. While HIV-positive patients with well-controlled viral loads and high CD4 counts are now being transplanted in specialized centers, "AIDS" as a clinical stage remains a classic absolute contraindication in standard surgical textbooks and NEET-PG curricula. **Analysis of Incorrect Options:** * **Age >70 (Relative):** While advanced age increases the risk of cardiovascular complications, it is not an absolute cutoff. "Physiological age" is prioritized over "chronological age." * **Portal Vein Thrombosis (Relative):** Previously a contraindication, it is now managed using thrombectomy or venous bypass techniques during the transplant. * **Severe Obesity (Relative):** While BMI >35-40 increases the risk of wound infections and metabolic complications, it is a relative contraindication that requires pre-operative weight management. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Extrahepatic malignancy, active extrahepatic sepsis, advanced cardiopulmonary disease, and active substance/alcohol abuse. * **MELD Score:** Used for prioritizing patients on the waiting list (based on Bilirubin, Creatinine, and INR). * **Milan Criteria:** Used to determine eligibility for patients with Hepatocellular Carcinoma (Single lesion ≤5cm or up to 3 lesions each ≤3cm).

Q: What is the most common malignancy observed after renal transplantation?

Skin cancer. **Explanation:** The correct answer is **Skin cancer**. Post-transplant patients are at a significantly higher risk of developing malignancies compared to the general population due to long-term **immunosuppressive therapy**, which impairs the body’s immune surveillance against oncogenic viruses and UV-damaged cells. **1. Why Skin Cancer is Correct:** Skin cancers, particularly **Squamous Cell Carcinoma (SCC)**, are the most common malignancies following renal transplantation. Unlike the general population where Basal Cell Carcinoma (BCC) is more frequent, in transplant recipients, SCC is more common (SCC:BCC ratio is reversed). Risk factors include prolonged immunosuppression, sun exposure, and infection with Human Papillomavirus (HPV). **2. Analysis of Incorrect Options:** * **Lymphoma (Option A):** While **Post-Transplant Lymphoproliferative Disorder (PTLD)** is a serious and well-known complication (often associated with Epstein-Barr Virus), it is less common than skin cancer. * **Renal Cell Carcinoma (Option B):** There is an increased risk of RCC in the native kidneys (especially in patients with acquired cystic kidney disease), but it does not surpass the incidence of skin malignancies. * **Adrenal Cancer (Option D):** This is a rare malignancy and is not specifically associated with the post-transplant immunosuppressed state. **Clinical Pearls for NEET-PG:** * **Most common malignancy overall:** Skin cancer (SCC > BCC). * **Most common non-skin malignancy:** Lymphoma (PTLD). * **Most common viral association:** EBV is linked to PTLD; HHV-8 is linked to Kaposi Sarcoma. * **Screening:** Transplant recipients require lifelong, annual dermatological evaluation. * **Management:** If malignancy occurs, the first step is often the reduction or modification of immunosuppressive agents (e.g., switching to mTOR inhibitors like Sirolimus, which have anti-tumor properties).

Q: Following liver transplantation, recurrence of primary disease in the liver most likely occurs in which of the following conditions?

Autoimmune hepatitis. **Explanation:** Recurrence of the primary disease is a significant long-term complication of liver transplantation. Among the options provided, **Autoimmune Hepatitis (AIH)** has the highest rate of recurrence, affecting approximately **20–30%** of recipients within five years. The underlying medical concept is that the patient’s systemic immune dysregulation persists even after the native organ is replaced; the recipient's immune system continues to produce autoantibodies and T-cells that attack the new graft. **Analysis of Options:** * **Autoimmune Hepatitis (AIH):** Recurrence is common and often requires lifelong titration of immunosuppressants (corticosteroids and azathioprine). * **Wilson Disease:** This is a genetic defect in copper metabolism (ATP7B gene) localized in the liver. Since the donor liver has normal genetics, the disease **does not recur**. * **Alpha-1 Antitrypsin (A1AT) Deficiency:** Similar to Wilson’s, this is a genetic metabolic disorder. A transplant from a donor with normal alleles (PiMM) effectively cures the patient; the new liver produces normal A1AT protein. * **Primary Biliary Cirrhosis (PBC):** While PBC can recur (now termed Primary Biliary Cholangitis), its recurrence rate and clinical impact are generally lower and slower to manifest compared to the aggressive nature of recurrent AIH. **NEET-PG High-Yield Pearls:** * **Most common indication for liver transplant (Global):** Hepatitis C (though decreasing due to DAAs) and NASH/NAFLD. * **Most common indication (India):** Decompensated Cirrhosis due to Hepatitis B or NASH. * **Disease with 0% recurrence:** Genetic/Metabolic disorders like Wilson disease and A1AT deficiency. * **Hepatocellular Carcinoma (HCC):** Recurrence is strictly monitored using the **Milan Criteria** to minimize post-transplant relapse.

Q: In orthotopic liver transplant, what is the anatomical site for the graft?

Anatomical liver position. In liver transplantation, the terminology used describes the anatomical placement of the donor organ relative to the recipient's native anatomy. **Explanation of the Correct Answer:** The term **"Orthotopic"** is derived from the Greek words *orthos* (straight/correct) and *topos* (place). In an **Orthotopic Liver Transplant (OLT)**, the recipient's diseased liver is completely removed (hepatectomy), and the donor graft is placed in the **anatomical liver position** (the right hypochondrium). This allows for the standard re-establishment of vascular and biliary connections (IVC, portal vein, hepatic artery, and bile duct) in their natural orientation. **Explanation of Incorrect Options:** * **Subhepatic and Infragastric spaces:** These refer to locations below the liver or stomach, respectively. Placing a liver here would be considered a **Heterotopic Transplant**. In heterotopic transplantation, the recipient's native liver is left in situ, and the donor liver is placed at an ectopic site. This is rarely performed today but was historically explored for temporary metabolic support or acute liver failure. **High-Yield Clinical Pearls for NEET-PG:** * **Standard of Care:** Orthotopic transplantation is the gold standard for end-stage liver disease. * **Vascular Anastomosis Sequence:** Typically, the Suprahepatic IVC is anastomosed first, followed by the Infrahepatic IVC, Portal Vein, Hepatic Artery, and finally the Biliary tree. * **Piggyback Technique:** A common modification where the recipient's IVC is preserved, and the donor liver is attached to the confluence of the hepatic veins. * **Most common indication:** Worldwide, it is Hepatitis C/Alcoholic Cirrhosis; in children, it is Biliary Atresia.

Q: What does xenograft mean?

Transplanting organs from one species to another. **Explanation:** The terminology of transplantation is based on the genetic relationship between the donor and the recipient. **1. Why Option A is correct:** A **Xenograft** (or Heterograft) refers to a transplant between members of different species (e.g., a porcine heart valve transplanted into a human). Because of the significant genetic disparity, xenografts are prone to **Hyperacute Rejection**, primarily mediated by pre-existing antibodies against alpha-gal antigens. **2. Why the other options are incorrect:** * **Option B (Allograft):** This is a transplant between genetically non-identical members of the **same species** (e.g., a kidney from a deceased human donor to a human recipient). This is the most common type of clinical transplant. * **Option C (Isograft/Syngeneic graft):** This refers to a transplant between **genetically identical** individuals, such as monozygotic (identical) twins. In this case, there is no risk of immunological rejection. * **Option D (Autograft):** This involves moving tissue from **one site to another within the same individual** (e.g., a skin graft from the thigh to the arm or a CABG using the Great Saphenous Vein). There is no risk of rejection. **Clinical Pearls for NEET-PG:** * **Hyperacute Rejection** is the hallmark of xenotransplantation, occurring within minutes due to pre-formed antibodies. * **Galα1,3-Gal (Alpha-gal)** is the major xenoantigen responsible for rejection in humans. * **Pigs** are currently considered the most suitable source for xenotransplantation due to physiological similarities and ease of breeding. * **Order of Rejection Risk:** Xenograft > Allograft > Isograft = Autograft.

Question 1

Which of the following is considered an extended criteria donor for kidney transplantation?

Accepted Answer

All the above

Answer

Donors with extremes of age

Answer

Donors with excess alcohol intake

Answer

Donors having cerebrovascular accident

Question 2

In which of the following conditions is liver transplantation indicated?

Accepted Answer

Primary biliary cirrhosis

Answer

Hemochromatosis

Answer

Sclerosing cholangitis without ulcerative colitis

Answer

Sclerosing cholangitis with ulcerative colitis

Question 3

Which of the following is an absolute contraindication to liver transplantation?

Accepted Answer

AIDS

Answer

Age >70

Answer

Portal vein thrombosis

Answer

Severe obesity

Question 4

What is the safest transplantation approach in liver disease?

Accepted Answer

Transplanting mesenchymal stem cells from adipose tissue into the liver

Answer

Directly transplanting embryonic stem cells into the liver

Answer

Transplanting donor hepatocytes into the liver

Answer

Injecting erythropoietin into the body

Question 5

What is the most common malignancy observed after renal transplantation?

Accepted Answer

Skin cancer

Answer

Lymphoma

Answer

Renal cell carcinoma

Answer

Adrenal cancer

Question 6

A 55-year-old man with idiopathic dilated cardiomyopathy receives a heart transplant. Which of the following is the most likely cause of death in this patient 2 years after transplantation?

Accepted Answer

Chronic vascular rejection

Answer

Acute cellular graft rejection

Answer

Aortic valve stenosis

Answer

Hyperacute graft rejection

Question 7

Following liver transplantation, recurrence of primary disease in the liver most likely occurs in which of the following conditions?

Accepted Answer

Autoimmune hepatitis

Answer

Wilson disease

Answer

Alpha-1 antitrypsin deficiency

Answer

Primary biliary cirrhosis

Question 8

In orthotopic liver transplant, what is the anatomical site for the graft?

Accepted Answer

Anatomical liver position

Answer

Subhepatic space

Answer

Infragastric space

Answer

Any of the above

Question 9

What is the most common viral infection following kidney transplantation?

Accepted Answer

Cytomegalovirus (CMV)

Answer

Epstein-Barr virus (EBV)

Answer

Herpes simplex virus (HSV)

Answer

Hepatitis B virus (HBV)

Question 10

What does xenograft mean?

Accepted Answer

Transplanting organs from one species to another

Answer

Transplanting organs from a member of the same species

Answer

Transplanting organs from twin to twin

Answer

Transplanting organs from one site to another in an individual

Transplant Surgery — MCQs

Transplant Surgery — MCQs

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