Transplant Surgery — MCQs

Transplant Surgery Indian Medical PG Practice Questions and MCQs

Question 21: Which of the following is NOT a part of "Triple therapy" immunosuppression for a post-renal transplant patient?

A. Prednisone
B. Cyclosporine
C. Azathioprine
D. Belatacept (Correct Answer)

Explanation: The "Triple Therapy" regimen is the gold standard for maintenance immunosuppression in post-renal transplant patients. It is designed to target different pathways of the immune response to maximize graft survival while minimizing the toxicity of any single drug. ### **Explanation of the Correct Answer** **D. Belatacept:** This is a selective T-cell costimulation blocker (binds to CD80 and CD86). While it is FDA-approved for prophylaxis of organ rejection, it is **not** part of the classic "Triple Therapy" regimen. It is typically used as an alternative to Calcineurin Inhibitors (CNIs) to avoid nephrotoxicity, but it is administered via intravenous infusion rather than the standard oral triple-drug protocol. ### **Analysis of Incorrect Options** The classic Triple Therapy consists of one drug from each of the following three categories: * **A. Prednisone (Corticosteroids):** Provides broad anti-inflammatory and immunosuppressive effects by inhibiting cytokine gene expression. * **B. Cyclosporine (Calcineurin Inhibitors):** Inhibits IL-2 production. In modern practice, **Tacrolimus** has largely replaced Cyclosporine due to better efficacy, but both are considered the "backbone" of triple therapy. * **C. Azathioprine (Antimetabolites):** Inhibits purine synthesis to prevent T-cell proliferation. In contemporary regimens, **Mycophenolate Mofetil (MMF)** is more commonly used than Azathioprine. ### **NEET-PG High-Yield Pearls** * **Standard Modern Triple Therapy:** Tacrolimus + Mycophenolate Mofetil (MMF) + Prednisolone. * **Side Effect Profile:** * **Cyclosporine:** Nephrotoxicity, Gingival hyperplasia, Hirsutism. * **Tacrolimus:** Nephrotoxicity, Neurotoxicity, Post-transplant Diabetes Mellitus (PTDM). * **MMF:** GI upset and Bone marrow suppression. * **Sirolimus (mTOR inhibitor):** Often used if CNIs must be withdrawn due to nephrotoxicity, but it impairs wound healing.

Question 22: In brain death, which of the following organs cannot be transplanted?

A. Brain (Correct Answer)
B. Heart
C. Liver
D. Kidney

Explanation: **Explanation:** The concept of **Brain Death** (Neurological Death) refers to the irreversible loss of all functions of the entire brain, including the brainstem. This state is the legal and clinical prerequisite for **Deceased Organ Donation**. **Why Brain is the Correct Answer:** The brain cannot be transplanted because it is the very organ that has undergone irreversible necrosis and cellular death in this scenario. Furthermore, medical science currently lacks the technology to reconnect the complex neural pathways of the spinal cord and cranial nerves required for a brain transplant. In the context of organ donation, the "donor" is defined by the death of the brain, making it the only organ in the list that is non-viable and medically impossible to transplant. **Analysis of Incorrect Options:** * **B, C, and D (Heart, Liver, Kidney):** These are the primary solid organs harvested from brain-dead donors. In brain death, while the brain has ceased to function, the heart continues to beat (often with pharmacological support), and systemic circulation is maintained via a ventilator. This ensures that the heart, liver, and kidneys remain **perfused and oxygenated**, preserving their viability for transplantation into a recipient. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for Brain Death Diagnosis:** Normothermia (>32°C), absence of metabolic encephalopathy, and absence of neuromuscular blockers/sedatives. * **Confirmatory Test:** The **Apnea Test** is the gold standard clinical test. * **Legal Framework:** In India, the **Transplantation of Human Organs Act (THOA), 1994** provides the legal definition and regulations for brain death and organ retrieval. * **Order of Ischemic Tolerance:** The heart and lungs have the shortest cold ischemia time (4–6 hours), while kidneys can be preserved the longest (up to 24–48 hours).

Question 23: Which of the following statements is NOT true regarding Milan criteria for liver transplantation?

A. Single tumor less than 5 cm in size
B. Three nodules, each less than 3 cm in size
C. More than 5 nodules (Correct Answer)
D. No extrahepatic disease

Explanation: The **Milan Criteria** are the gold standard guidelines used to determine the eligibility of patients with **Hepatocellular Carcinoma (HCC)** for liver transplantation. They were established to ensure optimal post-transplant survival rates (75% at 5 years) by selecting patients with low risk of tumor recurrence. ### **Explanation of the Correct Option** * **C. More than 5 nodules:** This is the **incorrect** statement. According to Milan criteria, the maximum number of nodules allowed is **three**. Having more than five nodules indicates advanced disease with a high risk of vascular invasion and recurrence, making the patient ineligible for standard transplantation. ### **Analysis of Other Options** * **A. Single tumor less than 5 cm:** This is a core component of the criteria. A solitary lesion must be $\leq$ 5 cm in diameter. * **B. Three nodules, each less than 3 cm:** If multiple tumors are present, there must be no more than three, and each individual nodule must be $\leq$ 3 cm in diameter. * **D. No extrahepatic disease:** For a transplant to be successful, the cancer must be localized to the liver. Any evidence of extrahepatic spread or **macrovascular invasion** (e.g., portal vein involvement) is an absolute contraindication. ### **High-Yield Clinical Pearls for NEET-PG** * **UCSF Criteria:** A slightly expanded version of Milan (Single lesion $\leq$ 6.5 cm OR $\leq$ 3 lesions with largest $\leq$ 4.5 cm and total diameter $\leq$ 8 cm). * **Bridging Therapy:** While waiting for a transplant, patients meeting Milan criteria may undergo TACE (Transarterial Chemoembolization) or RFA (Radiofrequency Ablation) to prevent tumor progression. * **Downstaging:** This refers to using local therapies to bring a tumor that is initially outside Milan criteria into the acceptable range for transplantation.

Question 24: Post-transplant nephropathy after 1 month is most likely due to which of the following?

A. Hepatitis C
B. HHV-6
C. Polyoma BK virus (Correct Answer)
D. Herpes simplex viruses

Explanation: **Explanation:** **Polyoma BK Virus** is the most common viral cause of renal allograft dysfunction (nephropathy) occurring typically within the first few months to a year post-transplant. The virus, which remains latent in the urinary tract of most healthy individuals, reactivates under the influence of potent immunosuppression (especially tacrolimus and mycophenolate mofetil). It leads to **BK Virus-Associated Nephropathy (BKVAN)**, characterized by a rising serum creatinine and histological features mimicking rejection (tubulitis and interstitial inflammation). **Analysis of Incorrect Options:** * **Hepatitis C (Option A):** While HCV can cause glomerulonephritis (like MPGN) in the long term, it is not a primary cause of acute/subacute post-transplant nephropathy within the first month. * **HHV-6 (Option B):** Human Herpesvirus 6 is associated with fever, skin rash, and bone marrow suppression post-transplant, but it is rarely a direct cause of nephropathy. * **Herpes Simplex Virus (Option D):** HSV typically presents with mucocutaneous lesions or systemic viremia (hepatitis/pneumonitis) rather than specific renal allograft parenchymal damage. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** The gold standard is a **renal biopsy** showing characteristic intranuclear inclusion bodies (ground-glass appearance) and positive SV40 staining. * **Screening:** Done via **decoy cells** in urine cytology (high sensitivity, low specificity) or **BK-PCR** in plasma (preferred for monitoring). * **Management:** The primary treatment is the **reduction of immunosuppressive therapy**. * **Timeline:** While hyperacute rejection occurs in minutes and acute rejection in days/weeks, BKVAN is a significant differential for graft dysfunction starting around 1–3 months post-surgery.

Question 25: Snover's triad in acute cellular rejection of liver transplantation includes all of the following except?

A. Portal inflammation
B. Endothelialitis
C. Cholangitis
D. Periportal fibrosis (Correct Answer)

Explanation: **Explanation:** Acute Cellular Rejection (ACR) of the liver typically occurs between day 5 and day 30 post-transplant. The diagnosis is confirmed histologically using the **Banff Criteria**, which is based on the classic **Snover’s Triad**. **Why Periportal Fibrosis is the Correct Answer:** Periportal fibrosis is a feature of **chronic rejection** or long-standing biliary complications, not acute cellular rejection. ACR is characterized by acute inflammatory changes rather than structural scarring or architectural distortion. **Analysis of Snover’s Triad (Incorrect Options):** The triad consists of the following three histological features: 1. **Portal Inflammation (Option A):** A mixed inflammatory infiltrate (predominantly lymphocytes, but also eosinophils and neutrophils) involving the portal tracts. 2. **Endothelialitis (Option B):** Also known as subendothelial venulitis. It involves inflammatory cells (lymphocytes) attaching to and undermining the endothelium of portal or central veins. This is the most specific sign of ACR. 3. **Bile Duct Inflammation/Damage (Option C):** Often referred to as **nonsuppurative cholangitis**, where inflammatory cells infiltrate the biliary epithelium, leading to nuclear pleomorphism and cytoplasmic vacuolization. **Clinical Pearls for NEET-PG:** * **Grading:** ACR is graded using the **Rejection Activity Index (RAI)** or **Banff Score**, which assigns 0–3 points to each component of the triad (Max score = 9). * **First Sign:** A sudden rise in liver enzymes (ALT/AST) and bilirubin is the clinical hallmark. * **Treatment:** The first-line treatment for ACR is **high-dose intravenous corticosteroids** (methylprednisolone "pulses"). * **Chronic Rejection:** Characterized by "Vanishing Bile Duct Syndrome" (ductopenia) and obliterative arteriopathy.

Question 26: Which of the following criteria indicates an extended criteria donor for liver transplantation?

A. Age greater than 60 years
B. Hepatitis C positive (Correct Answer)
C. Primary sclerosing cholangitis
D. All of the above

Explanation: **Explanation:** **Extended Criteria Donors (ECD)**, also known as marginal donors, are those who do not meet the standard criteria for organ donation but are utilized to bridge the gap between organ demand and availability. These organs carry a higher risk of initial poor function or graft failure but can be life-saving for specific recipients. **Why Hepatitis C Positive is the Correct Answer:** Historically, Hepatitis C (HCV) positive livers were considered unsuitable. However, they are now classified as ECD organs. With the advent of highly effective **Direct-Acting Antivirals (DAAs)**, HCV-positive grafts can be safely transplanted into HCV-positive recipients or even HCV-negative recipients (with informed consent and post-transplant antiviral therapy), as the cure rate for the virus is now near 100%. **Analysis of Other Options:** * **Age greater than 60 years (Option A):** While advanced age is a factor in ECD, the standard threshold used in most liver transplant scoring systems (like the Donor Risk Index) is typically **greater than 70 years**, not 60. * **Primary Sclerosing Cholangitis (Option C):** PSC is an **indication** for receiving a transplant, not a criterion for being a donor. Donor criteria focus on the health and quality of the donor's liver (e.g., steatosis, viral status, ischemia time). **High-Yield Clinical Pearls for NEET-PG:** * **Common ECD Criteria:** Donor age >70, macrosteatosis >30%, prolonged cold ischemia time (>12 hours), hypernatremia (Sodium >155 mEq/L), and donors with positive serology (HCV, HBcAb). * **MELD Score:** Used to prioritize recipients based on the severity of their liver disease (incorporates Bilirubin, Creatinine, and INR). * **Milan Criteria:** Used to determine eligibility for liver transplant in patients with Hepatocellular Carcinoma (Single lesion <5cm or up to 3 lesions <3cm each).

Question 27: Which of the following is NOT an indication for liver transplantation?

A. Cirrhosis
B. Primary hepatic malignancy
C. Acute fulminant liver failure
D. None of the above (Correct Answer)

Explanation: **Explanation:** The correct answer is **D (None of the above)** because all the listed conditions (Cirrhosis, Primary hepatic malignancy, and Acute fulminant liver failure) are well-established indications for liver transplantation. 1. **Cirrhosis (Option A):** Chronic Liver Disease (CLD) resulting in end-stage liver disease is the most common indication for transplantation. This includes cirrhosis caused by Hepatitis C, Hepatitis B, Alcoholic Liver Disease, and Non-Alcoholic Steatohepatitis (NASH). 2. **Primary Hepatic Malignancy (Option B):** Specifically, **Hepatocellular Carcinoma (HCC)** is a major indication, provided it meets the **Milan Criteria** (single lesion ≤5 cm or up to 3 lesions each ≤3 cm, with no extrahepatic spread or vascular invasion). 3. **Acute Fulminant Liver Failure (Option C):** This refers to rapid-onset liver failure (within 8 weeks of jaundice) in a patient without prior liver disease. Common causes include Paracetamol (Acetaminophen) toxicity, viral hepatitis (A, B, or E), and Wilson’s disease. **High-Yield Clinical Pearls for NEET-PG:** * **MELD Score (Model for End-Stage Liver Disease):** Uses Bilirubin, Creatinine, and INR to prioritize patients on the transplant waiting list. * **Most Common Indication (Global):** Hepatitis C-related cirrhosis (historically) and NASH (rising). * **Most Common Indication in Children:** Biliary Atresia. * **Absolute Contraindications:** Extrahepatic malignancy, active systemic infection, active substance abuse, and advanced cardiopulmonary disease. * **King’s College Criteria:** Used specifically to determine the prognosis and need for transplantation in Acute Liver Failure.

Question 28: What is the most common indication for liver transplantation in adults?

A. Portal vein thrombosis
B. Cirrhosis (Correct Answer)
C. Biliary atresia
D. None of the above

Explanation: **Explanation:** **Liver transplantation** is the definitive treatment for end-stage liver disease (ESLD) and acute liver failure. **Why Cirrhosis is Correct:** In adults, **Cirrhosis** is the most common indication for liver transplantation worldwide. Cirrhosis represents the final common pathway of various chronic liver insults, leading to irreversible scarring and loss of function. While the underlying etiology of cirrhosis varies—historically **Hepatitis C** was the leading cause, but it is currently being surpassed by **Non-Alcoholic Steatohepatitis (NASH/NAFLD)** and **Alcoholic Liver Disease**—the clinical state of cirrhosis remains the primary reason for transplant. **Analysis of Incorrect Options:** * **Portal Vein Thrombosis (A):** This is often a *complication* of cirrhosis or a contraindication/technical challenge during surgery, rather than a primary indication for the transplant itself. * **Biliary Atresia (C):** This is the **most common indication for liver transplantation in the pediatric population**, not adults. It involves the congenital absence or obstruction of the bile ducts. **High-Yield Clinical Pearls for NEET-PG:** * **MELD Score (Model for End-Stage Liver Disease):** Used to prioritize adult patients on the transplant waiting list. It uses Serum Bilirubin, Creatinine, and INR. * **PELD Score:** Used for pediatric patients (under age 12). * **Milan Criteria:** Used to determine eligibility for transplant in patients with **Hepatocellular Carcinoma (HCC)** (Single lesion <5cm or up to 3 lesions each <3cm). * **Most common cause of death post-transplant:** Infection (early) and Cardiovascular disease/Malignancy (late).

Question 29: Which type of transplant graft has the least chance of recipient failure?

A. Allograft
B. Isograft (Correct Answer)
C. Xenograft
D. Heterotopic Graft

Explanation: **Explanation:** The success of a transplant depends primarily on the **genetic compatibility** between the donor and the recipient. The less the antigenic disparity, the lower the risk of immune-mediated rejection. **Why Isograft is Correct:** An **Isograft (Syngeneic graft)** is a transplant between genetically identical individuals of the same species, such as **monozygotic (identical) twins**. Because the Human Leukocyte Antigens (HLA) are identical, the recipient’s immune system does not recognize the graft as "foreign." Consequently, there is virtually no risk of rejection, and long-term immunosuppression is generally not required. This makes it the graft with the least chance of failure. **Why Other Options are Incorrect:** * **Allograft:** This is a transplant between genetically different members of the same species (e.g., from a deceased donor or a sibling). This is the most common type of clinical transplant but requires lifelong immunosuppression to prevent rejection. * **Xenograft:** This involves transplantation between different species (e.g., pig heart to human). These carry the highest risk of failure due to **hyperacute rejection** mediated by pre-existing antibodies. * **Heterotopic Graft:** This refers to the **anatomical site** of the transplant (placing the organ in a different location, like a kidney in the iliac fossa) rather than the genetic relationship. It does not inherently determine the immunological failure rate. **High-Yield Clinical Pearls for NEET-PG:** * **Autograft:** Transplant within the same individual (e.g., skin graft, CABG). It has **zero** chance of rejection. (If "Autograft" were an option, it would be the most successful). * **First Successful Human Transplant:** A kidney transplant performed by Joseph Murray in 1954 between **identical twins** (Isograft). * **Order of Rejection Risk:** Autograft < Isograft < Allograft < Xenograft.

Question 30: In renal transplant surgery, where is the transplanted kidney typically placed?

A. Iliac fossa (Correct Answer)
B. Subcostal area
C. Loin
D. None of the above

Explanation: In renal transplantation, the **Iliac Fossa** (Option A) is the preferred site for placement of the donor kidney. This is known as **heterotopic transplantation**, meaning the organ is placed in a location different from its original anatomical position. ### Why the Iliac Fossa? 1. **Vascular Access:** The iliac fossa provides easy access to the **External Iliac vessels**. The donor renal artery is typically anastomosed to the Internal or External Iliac artery, and the donor renal vein to the External Iliac vein. 2. **Ureteric Length:** Placing the kidney in the pelvis minimizes the distance the donor ureter must travel to reach the bladder (**Ureteroneocystostomy**), reducing the risk of ureteric ischemia or necrosis. 3. **Protection and Access:** The bony pelvis protects the graft, yet it remains superficial enough for easy clinical palpation and ultrasound-guided biopsies. ### Why other options are incorrect: * **Subcostal area (B) and Loin (C):** These represent the **orthotopic** position (the native renal bed). This site is avoided because it requires a deeper dissection, offers more difficult vascular anastomosis, and necessitates a much longer ureteric length, increasing surgical morbidity. ### High-Yield Clinical Pearls for NEET-PG: * **Side of Placement:** Usually, the **left donor kidney** is transplanted into the **right iliac fossa** of the recipient (and vice versa). This "flips" the kidney so the renal pelvis is anterior and the vessels are posterior, facilitating easier surgical access. * **Gibson Incision:** The standard surgical approach used to access the extraperitoneal iliac fossa. * **Native Kidneys:** These are generally **not removed** unless they are causing complications like refractory hypertension, recurrent infections, or are too large (e.g., Autosomal Dominant Polycystic Kidney Disease).

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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