Transplant Surgery — MCQs
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Which of the following is considered an extended criteria donor for kidney transplantation?
In which of the following conditions is liver transplantation indicated?
Which of the following is an absolute contraindication to liver transplantation?
What is the safest transplantation approach in liver disease?
What is the most common malignancy observed after renal transplantation?
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?
Following liver transplantation, recurrence of primary disease in the liver most likely occurs in which of the following conditions?
In orthotopic liver transplant, what is the anatomical site for the graft?
What is the most common viral infection following kidney transplantation?
What does xenograft mean?
Transplant Surgery Indian Medical PG Practice Questions and MCQs
Question 11: Which of the following is considered an extended criteria donor for kidney transplantation?
- A. Donors with extremes of age
- B. Donors with excess alcohol intake
- C. Donors having cerebrovascular accident
- D. All the above (Correct Answer)
Explanation: **Explanation:** In kidney transplantation, an **Extended Criteria Donor (ECD)** refers to a deceased donor whose kidneys carry a higher risk of graft failure compared to standard criteria donors (SCD). The concept was developed to expand the donor pool due to the increasing organ shortage. The correct answer is **D (All the above)** because the definition of ECD is primarily based on age and specific clinical comorbidities that predict reduced graft survival: 1. **Extremes of Age (Option A):** By definition, any donor **≥ 60 years** is an ECD. Additionally, donors aged **50–59 years** are classified as ECD if they meet at least two of the following: history of hypertension, terminal serum creatinine >1.5 mg/dL, or cause of death being a cerebrovascular accident. 2. **Cerebrovascular Accident (Option C):** CVA as a cause of death is a core component of the ECD criteria (for the 50–59 age bracket) as it often indicates underlying systemic vascular disease, which may affect the microvasculature of the kidney. 3. **Excess Alcohol Intake (Option B):** While not part of the formal UNOS point-based definition, clinical practice and various transplant protocols categorize donors with significant lifestyle comorbidities (like chronic alcoholism or heavy smoking) as "marginal" or extended criteria due to the risk of associated systemic diseases. **High-Yield Facts for NEET-PG:** * **Standard Criteria Donor (SCD):** Ideally a young donor (<50 years) who died of trauma with no history of hypertension or renal dysfunction. * **ECD Outcomes:** These kidneys have a **1.7 times higher risk** of graft failure compared to SCD kidneys but are still preferred over remaining on long-term dialysis. * **Cold Ischemia Time:** For ECD kidneys, it is crucial to keep cold ischemia time **<24 hours** to minimize delayed graft function (DGF). * **Dual Kidney Transplant:** Sometimes, two ECD kidneys are transplanted into a single recipient if the nephron mass of one is deemed insufficient.
Question 12: In which of the following conditions is liver transplantation indicated?
- A. Hemochromatosis
- B. Primary biliary cirrhosis (Correct Answer)
- C. Sclerosing cholangitis without ulcerative colitis
- D. Sclerosing cholangitis with ulcerative colitis
Explanation: **Explanation:** Liver transplantation is the definitive treatment for end-stage liver disease (ESRD). Among the options provided, **Primary Biliary Cirrhosis (PBC)**—now often termed Primary Biliary Cholangitis—is a classic and well-established indication for transplantation. It is a chronic cholestatic disease where progressive destruction of small bile ducts leads to cirrhosis and liver failure. Transplantation is indicated when patients develop complications like intractable pruritus, bilirubin >6 mg/dL, or hepatic encephalopathy. **Analysis of Options:** * **Primary Biliary Cirrhosis (Correct):** It is one of the most common autoimmune indications for transplant. Survival rates post-transplant are excellent (80-90% at 5 years). * **Hemochromatosis (Incorrect):** While it can lead to cirrhosis, it is often considered a relative contraindication or a high-risk indication because these patients have significantly poorer outcomes post-transplant due to iron-related cardiac complications and increased risk of infections (e.g., *Listeria*, *Vibrio*). * **Sclerosing Cholangitis (Incorrect):** While Primary Sclerosing Cholangitis (PSC) is an indication for transplant, the presence of **Ulcerative Colitis (UC)** significantly complicates the prognosis. Patients with PSC and UC have a much higher risk of developing **cholangiocarcinoma** and colorectal cancer. In the context of this specific question, PBC is the more straightforward, "textbook" indication compared to the complexities of PSC management. **High-Yield Clinical Pearls for NEET-PG:** * **Most common indication (Adults):** Hepatitis C related cirrhosis (historically) and NASH/Alcoholic Liver Disease (currently). * **Most common indication (Children):** Biliary Atresia. * **MELD Score:** Used to prioritize patients on the transplant waiting list (based on Bilirubin, Creatinine, and INR). * **Absolute Contraindications:** Extrahepatic malignancy, active systemic infection, advanced cardiopulmonary disease, and active substance abuse.
Question 13: Which of the following is an absolute contraindication to liver transplantation?
- A. Age >70
- B. Portal vein thrombosis
- C. Severe obesity
- D. AIDS (Correct Answer)
Explanation: **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).
Question 14: What is the safest transplantation approach in liver disease?
- A. Directly transplanting embryonic stem cells into the liver
- B. Transplanting donor hepatocytes into the liver
- C. Transplanting mesenchymal stem cells from adipose tissue into the liver (Correct Answer)
- D. Injecting erythropoietin into the body
Explanation: **Explanation:** The correct answer is **C: Transplanting mesenchymal stem cells (MSCs) from adipose tissue into the liver.** **Why it is correct:** Mesenchymal stem cells (MSCs) are multipotent cells that possess unique immunomodulatory and anti-inflammatory properties. Adipose tissue is considered the **safest and most practical source** because it is easily accessible via minimally invasive procedures (liposuction), yields a high concentration of MSCs, and avoids the ethical controversies associated with embryonic cells. Clinically, MSCs promote liver regeneration by secreting growth factors and reducing fibrosis without the high risk of malignant transformation or acute immune rejection. **Why other options are incorrect:** * **Option A:** Embryonic stem cells (ESCs) carry a significant risk of **teratoma formation** (tumorigenicity) and face major ethical and legal hurdles, making them unsafe for routine clinical transplantation. * **Option B:** Hepatocyte transplantation is limited by the poor survival of donor cells in a diseased environment, the requirement for high-quality donor livers (which are scarce), and the risk of **portal vein thrombosis** or embolic events during infusion. * **Option D:** Erythropoietin (EPO) is primarily used to treat anemia. While it may have minor cytoprotective effects, it is not a "transplantation approach" and does not address the underlying architectural loss of liver tissue. **Clinical Pearls for NEET-PG:** * **Source of MSCs:** Bone marrow and adipose tissue are the primary sources; however, adipose-derived MSCs (AD-MSCs) are often preferred due to higher cell yield. * **Immunomodulation:** MSCs are "immuno-privileged" (low MHC I, no MHC II expression), reducing the need for aggressive immunosuppression. * **Standard of Care:** While stem cell therapy is an emerging "bridge" or alternative, **Orthotopic Liver Transplantation (OLT)** remains the definitive gold standard for end-stage liver disease (ESLD).
Question 15: What is the most common malignancy observed after renal transplantation?
- A. Lymphoma
- B. Renal cell carcinoma
- C. Skin cancer (Correct Answer)
- D. Adrenal cancer
Explanation: **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).
Question 16: 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?
- A. Acute cellular graft rejection
- B. Aortic valve stenosis
- C. Chronic vascular rejection (Correct Answer)
- D. Hyperacute graft rejection
Explanation: ### Explanation The correct answer is **Chronic vascular rejection**, specifically known as **Cardiac Allograft Vasculopathy (CAV)**. #### 1. Why Chronic Vascular Rejection is Correct In heart transplantation, the timeline of complications is a critical high-yield concept. While infections and acute rejection dominate the first year, **Chronic Vascular Rejection** is the leading cause of late graft failure and death after the first post-transplant year. * **Mechanism:** It involves concentric, diffuse intimal hyperplasia of the coronary arteries. Unlike typical atherosclerosis, it affects the entire length of the vessel (both intramyocardial and epicardial). * **Clinical Presentation:** Because the donor heart is denervated, patients do not experience typical angina. Instead, they present with "silent" myocardial infarction, heart failure, or sudden cardiac death. #### 2. Why Other Options are Incorrect * **A. Acute Cellular Graft Rejection:** This typically occurs within the first few weeks to months (usually <6 months). While it can occur later if immunosuppression is tapered, it is not the most common cause of death at 2 years. * **B. Aortic Valve Stenosis:** This is a degenerative or congenital valvular pathology and is not a specific or common complication of heart transplantation. * **D. Hyperacute Graft Rejection:** This occurs within **minutes to hours** due to pre-formed ABO or HLA antibodies (Type II hypersensitivity). It is now rare due to mandatory cross-matching. #### 3. NEET-PG High-Yield Pearls * **Most common cause of death <1 year:** Infection or Acute Rejection. * **Most common cause of death >1 year:** Chronic Rejection (CAV) and Malignancy (especially Lymphoma/PTLD). * **Pathology of CAV:** Diffuse, concentric narrowing (vs. eccentric focal plaques in normal CAD). * **Diagnosis:** Annual coronary angiography or intravascular ultrasound (IVUS) is often required because the patient lacks sensation (denervated heart).
Question 17: Following liver transplantation, recurrence of primary disease in the liver most likely occurs in which of the following conditions?
- A. Wilson disease
- B. Autoimmune hepatitis (Correct Answer)
- C. Alpha-1 antitrypsin deficiency
- D. Primary biliary cirrhosis
Explanation: **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.
Question 18: In orthotopic liver transplant, what is the anatomical site for the graft?
- A. Anatomical liver position (Correct Answer)
- B. Subhepatic space
- C. Infragastric space
- D. Any of the above
Explanation: 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.
Question 19: What is the most common viral infection following kidney transplantation?
- A. Epstein-Barr virus (EBV)
- B. Herpes simplex virus (HSV)
- C. Cytomegalovirus (CMV) (Correct Answer)
- D. Hepatitis B virus (HBV)
Explanation: ### Explanation **Cytomegalovirus (CMV)** is the most common clinically significant viral infection following kidney transplantation, typically occurring within the first **1 to 6 months** post-transplant (the period of maximal immunosuppression). #### Why CMV is the Correct Answer: CMV is a ubiquitous double-stranded DNA virus (HHV-5). In transplant recipients, it occurs either due to **primary infection** (seronegative recipient receiving a seropositive organ, D+/R-) or **reactivation** of a latent infection in the recipient. It is a major cause of morbidity, leading to "CMV syndrome" (fever, malaise, leukopenia) or tissue-invasive disease (pneumonitis, hepatitis, and GI ulcerations). It also increases the risk of graft rejection and opportunistic fungal infections. #### Analysis of Incorrect Options: * **A. Epstein-Barr virus (EBV):** While significant, it is less common than CMV. Its primary clinical importance lies in its association with **Post-Transplant Lymphoproliferative Disorder (PTLD)**. * **B. Herpes simplex virus (HSV):** HSV-1 and HSV-2 reactivations are common but usually present as self-limiting mucocutaneous lesions. Prophylaxis with Acyclovir has significantly reduced its incidence. * **D. Hepatitis B virus (HBV):** This is a chronic viral infection. While it can complicate the long-term course and lead to cirrhosis, it is not the most common post-transplant viral infection in the acute/subacute period. #### High-Yield Clinical Pearls for NEET-PG: * **Drug of Choice:** **Valganciclovir** (prophylaxis) and **Ganciclovir** (treatment). * **Histology:** Look for **"Owl’s eye"** intranuclear inclusion bodies. * **BK Virus:** Another high-yield virus to remember; it causes **BKV-associated nephropathy**, leading to a rise in creatinine that mimics graft rejection. * **Timeline:** Most viral infections (CMV, EBV, BK) occur in the **mid-post-transplant period** (1–6 months). Infections in the first month are usually bacterial/surgical site-related.
Question 20: What does xenograft mean?
- A. Transplanting organs from one species to another (Correct Answer)
- B. Transplanting organs from a member of the same species
- C. Transplanting organs from twin to twin
- D. Transplanting organs from one site to another in an individual
Explanation: **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.
Practice by Chapter
Immunology of Transplantation
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Immunosuppression
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Organ Procurement
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Kidney Transplantation
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Liver Transplantation
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Pancreas Transplantation
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Heart Transplantation
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Lung Transplantation
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Small Bowel Transplantation
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Complications of Transplantation
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Transplantation in Special Populations
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Ethical Issues in Transplantation
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