Transplant Surgery — MCQs

A 34-year-old patient with chronic glomerulonephritis has been receiving hemodialysis for the last three years and is awaiting renal transplantation from a cadaver donor. His blood type is A+ and he has been receiving transfusions for the past six months. Which of the following factors contraindicate renal transplantation in this patient?

Q47Easy

What is the most common indication for liver transplantation in end-stage liver disease?

Q48Medium

What describes a reduced liver transplant?

Q49Medium

All are common opportunistic infections seen early in renal transplant recipients, EXCEPT:

Q50Easy

Which of the following is an absolute contraindication for renal transplant?

Transplant Surgery Indian Medical PG Practice Questions and MCQs

Question 41: Which of the following are long-term complications (> 10 years) of renal transplantation?

A. Malignancy and viral infection (Correct Answer)
B. Malignancy and viral infection
C. Bacterial infection, acute graft versus host reaction, and viral infection
D. Bacterial infection, malignancy, and psychosis

Explanation: **Explanation:** The long-term survival of renal transplant recipients is primarily challenged by complications arising from chronic immunosuppression. Beyond the first decade (10+ years), the cumulative exposure to immunosuppressive agents significantly increases the risk of **Malignancy** and **Viral Infections**. 1. **Malignancy:** This is a leading cause of late mortality. The risk is 3–5 times higher than the general population. The most common are **Skin Cancers** (Squamous Cell Carcinoma being most frequent) and **Post-Transplant Lymphoproliferative Disorder (PTLD)**, often associated with the Epstein-Barr Virus (EBV). 2. **Viral Infections:** While acute bacterial infections dominate the early post-op period, chronic viral infections (like **CMV, BK virus, and HPV**) persist or reactivate in the long term due to impaired T-cell surveillance. **Analysis of Incorrect Options:** * **Bacterial Infections:** These are typically **early** complications (within the first month) related to surgical sites, catheters, or pneumonia. While they can occur late, they are not the defining "long-term" hallmark compared to malignancy. * **Acute Graft Versus Host Disease (GVHD):** This is rare in renal transplants (more common in liver or bone marrow) and occurs **early** in the post-transplant course, not after 10 years. * **Psychosis:** While steroid-induced psychosis can occur, it is usually an **acute** side effect seen during high-dose induction or rejection therapy, not a standard 10-year complication. **High-Yield Pearls for NEET-PG:** * **Most common malignancy post-transplant:** Skin cancer (SCC > BCC). * **Most common viral infection:** Cytomegalovirus (CMV). * **BK Virus:** Associated with ureteral stenosis and nephropathy in renal allografts. * **Leading cause of death with a functioning graft:** Cardiovascular disease (IHD).

Question 42: Steroids are used in transplantation for what primary purpose?

A. To prevent graft rejection (Correct Answer)
B. To prevent infection
C. To speed up recovery
D. To enhance immunity

Explanation: **Explanation:** **1. Why Option A is Correct:** Steroids (Corticosteroids like Prednisolone) are a cornerstone of immunosuppressive therapy in organ transplantation. Their primary mechanism is to **prevent and treat graft rejection** by inhibiting the inflammatory response. They act by blocking the expression of various cytokine genes (specifically **IL-1, IL-2, IL-6, and TNF-α**) and inhibiting T-cell activation and proliferation. By suppressing the recipient's immune system, steroids prevent it from recognizing and attacking the donor organ as foreign tissue. **2. Why Other Options are Incorrect:** * **Option B:** Steroids actually **increase** the risk of infection because they suppress the immune system’s ability to fight pathogens. * **Option C:** While steroids reduce inflammation, they can actually **delay** wound healing and recovery due to their catabolic effects on protein and inhibition of fibroblast activity. * **Option D:** Steroids are **immunosuppressants**, meaning they decrease or "blunt" immunity rather than enhancing it. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Steroids bind to intracellular receptors, translocate to the nucleus, and interfere with the transcription factor **NF-κB**. * **Pulse Therapy:** High-dose intravenous **Methylprednisolone** is the "gold standard" for treating episodes of **acute cellular rejection**. * **Side Effects:** Long-term steroid use is associated with high-yield complications: Cushingoid features, osteoporosis, hyperglycemia (steroid-induced diabetes), cataracts, and peptic ulcers. * **Triple Therapy:** In modern transplant protocols, steroids are typically used as part of a "Triple Drug Regimen" alongside a Calcineurin Inhibitor (e.g., Tacrolimus) and an Antimetabolite (e.g., Mycophenolate Mofetil).

Question 43: What is the principal cause of death in renal transplant patients?

A. Uremia
B. Malignancy
C. Rejection
D. Infection (Correct Answer)

Explanation: **Explanation:** In renal transplant recipients, **Infection** remains the leading cause of mortality worldwide. This is primarily due to the lifelong requirement for **maintenance immunosuppression** (such as Calcineurin inhibitors, Mycophenolate Mofetil, and Steroids), which impairs the host's cell-mediated and humoral immunity. While cardiovascular disease is a major competitor for the top cause of death in long-term survivors, most standardized exams and textbooks (like Bailey & Love) identify infection as the principal cause, especially in the early post-transplant period. **Analysis of Options:** * **Infection (Correct):** Immunosuppression predisposes patients to opportunistic infections (CMV, BK virus, Fungal) and common bacterial pathogens. Sepsis is the terminal event in many cases. * **Uremia (Incorrect):** With the availability of hemodialysis and the option of re-transplantation, patients rarely die of uremia today. If a graft fails, the patient simply returns to dialysis. * **Malignancy (Incorrect):** While transplant patients have a higher risk of cancers (e.g., Squamous Cell Carcinoma of skin, PTLD) due to chronic immunosuppression, it is a late complication and less common than infectious mortality. * **Rejection (Incorrect):** Rejection leads to **graft loss**, not necessarily patient death. Modern HLA matching and immunosuppressive protocols have significantly reduced the incidence of fatal acute rejection. **Clinical Pearls for NEET-PG:** 1. **Most common viral infection:** Cytomegalovirus (CMV), typically occurring 1–6 months post-transplant. 2. **Most common malignancy:** Skin cancer (Squamous Cell Carcinoma); however, **PTLD** (Post-Transplant Lymphoproliferative Disorder) is highly associated with EBV. 3. **Hyperacute Rejection:** Occurs within minutes due to pre-formed antibodies (Type II Hypersensitivity). 4. **Chronic Rejection:** Now often termed "Chronic Allograft Nephropathy," it is the most common cause of late graft failure.

Question 44: Renal transplantation from a non-genetically related person is an example of?

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

Explanation: **Explanation:** The correct answer is **Allograft**. This classification is based on the genetic relationship between the donor and the recipient. **1. Why Allograft is Correct:** An **Allograft** (also known as a homograft) is a transplant between two genetically non-identical members of the same species. Since a "non-genetically related person" belongs to the same species (human) but has a different genetic makeup, this is the standard category for most human organ transplants, including those from deceased donors or unrelated living donors. **2. Analysis of Incorrect Options:** * **Xenograft (or Heterograft):** These terms are synonymous. They refer to a transplant between members of **different species** (e.g., a porcine heart valve or a primate kidney transplanted into a human). * **Isograft (or 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. * **Autograft:** (Though not listed, a common term) This is a transplant from one part of the body to another in the **same individual** (e.g., a skin graft or CABG). **3. NEET-PG Clinical Pearls:** * **Hyperacute Rejection:** Occurs within minutes to hours due to pre-formed antibodies (Type II hypersensitivity). It is the primary reason for cross-matching. * **Most Common Site:** The transplanted kidney is usually placed in the **iliac fossa** (extraperitoneal). The renal artery is typically anastomosed to the internal or external iliac artery. * **Immunosuppression:** The "Triple Drug Therapy" usually consists of a Calcineurin inhibitor (Tacrolimus), an antiproliferative agent (Mycophenolate Mofetil), and Corticosteroids.

Question 45: The greatest chance for long-term survival of an allograft would be expected with which type of transplant?

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

Explanation: The correct answer is **Cornea transplant**. ### **Explanation** The primary reason for the high success rate and long-term survival of corneal allografts is the concept of **"Immunological Privilege."** Unlike other organs, the cornea is naturally **avascular** (lacks blood vessels and lymphatics). This prevents the host’s immune cells (T-lymphocytes) from reaching the graft and prevents graft antigens from reaching the regional lymph nodes (afferent blockade). Consequently, corneal transplants often do not require HLA matching and have the lowest rates of rejection among all allografts, even with minimal systemic immunosuppression. ### **Why other options are incorrect:** * **Kidney, Heart, and Liver transplants:** These are **solid organ transplants** that are highly vascularized. They require strict HLA matching (especially kidneys) and lifelong, potent systemic immunosuppression to prevent T-cell mediated rejection. * **Liver transplant:** While the liver is considered "immunologically tolerant" compared to the heart or kidney (it can sometimes survive across ABO incompatibility), it still carries a significantly higher risk of rejection than the cornea due to its massive vascular bed and exposure to the systemic immune system. ### **High-Yield Clinical Pearls for NEET-PG:** * **Privileged Sites:** Besides the cornea, other immunologically privileged sites include the **testes, brain, and anterior chamber of the eye.** * **Rejection Type:** The most common cause of corneal graft failure is **Type IV (delayed-type) hypersensitivity.** * **Storage:** Corneas are commonly stored in **McCarey-Kaufman (MK) medium** (up to 4 days) or **Optisol** (up to 14 days). * **Order of Rejection Risk:** Generally, Skin > Islets > Heart/Kidney > Liver > Cornea (Least likely to reject).

Question 46: A 34-year-old patient with chronic glomerulonephritis has been receiving hemodialysis for the last three years and is awaiting renal transplantation from a cadaver donor. His blood type is A+ and he has been receiving transfusions for the past six months. Which of the following factors contraindicate renal transplantation in this patient?

A. Autonomic neuropathy of the recipient
B. Two antigens of HLA match with the cadaver donor
C. Donor blood group B+ (Correct Answer)
D. Recipient blood hemoglobin level of 6.0 g/dL

Explanation: **Explanation:** The core principle of renal transplantation is **ABO compatibility**. In this case, the recipient is blood type **A+**, and the donor is **B+**. This is an absolute contraindication because the recipient possesses pre-existing anti-B antibodies. If transplanted, these antibodies would bind to the B-antigens on the donor vascular endothelium, triggering the complement cascade and leading to **Hyperacute Rejection (HAR)**. HAR occurs within minutes to hours and results in irreversible graft thrombosis and necrosis. **Analysis of Incorrect Options:** * **A. Autonomic neuropathy:** While it can complicate post-operative management (e.g., neurogenic bladder or gastroparesis), it is a common complication of chronic kidney disease/diabetes and is **not** a contraindication to transplant. * **B. Two HLA antigen match:** In cadaveric transplants, even a zero-antigen match is not a contraindication, provided the cross-match is negative. A two-antigen match actually improves long-term graft survival compared to a zero-match. * **D. Hemoglobin 6.0 g/dL:** Anemia is expected in ESRD patients due to erythropoietin deficiency. While optimization is preferred, a low hemoglobin level is a reversible condition and not a contraindication; it can be managed with perioperative transfusions or EPO. **High-Yield Clinical Pearls for NEET-PG:** * **Hyperacute Rejection:** Mediated by pre-formed antibodies (Type II Hypersensitivity). The kidney turns "blue and mottled" on the table. * **ABO Incompatibility:** The only exception is "ABO-incompatible transplantation" using specialized protocols (plasmapheresis and rituximab), but in standard NEET-PG questions, it remains a primary contraindication. * **Cross-matching:** A positive **Complement-Dependent Cytotoxicity (CDC) cross-match** (recipient serum + donor lymphocytes) is an absolute contraindication. * **Rh Factor:** Unlike blood transfusion, the Rh factor (D antigen) is not expressed on renal tissue; therefore, Rh incompatibility is **not** a contraindication for kidney transplant.

Question 47: What is the most common indication for liver transplantation in end-stage liver disease?

A. Wilson's disease
B. Chronic hepatitis B
C. Chronic hepatitis C (Correct Answer)
D. Alcoholic liver injury

Explanation: **Explanation:** The most common indication for liver transplantation (LT) globally, and historically the leading cause of end-stage liver disease (ESLD) requiring transplant, is **Chronic Hepatitis C (HCV)**. While the advent of highly effective Direct-Acting Antivirals (DAAs) is changing the landscape, HCV-related cirrhosis and its complication, Hepatocellular Carcinoma (HCC), remain the top reasons for LT in most international registries. **Analysis of Options:** * **Chronic Hepatitis C (Correct):** It is the leading cause of cirrhosis and HCC worldwide. Even with curative antiviral therapy, patients with established cirrhosis remain at risk for decompensation and malignancy, necessitating transplantation. * **Alcoholic Liver Injury (Incorrect):** This is the **second most common** indication globally. In some specific Western regions, it is currently surpassing HCV due to better viral management, but HCV remains the standard answer for exams based on cumulative data. * **Chronic Hepatitis B (Incorrect):** While a major cause of cirrhosis in Asia and Africa, the availability of effective suppressive therapy (like Tenofovir) and widespread vaccination has made it a less frequent indication for transplant compared to HCV. * **Wilson’s Disease (Incorrect):** This is a common **metabolic** cause for transplant, especially in the pediatric population or young adults presenting with fulminant hepatic failure, but it is rare compared to viral and alcoholic etiologies. **High-Yield Clinical Pearls for NEET-PG:** * **Most common indication in children:** Biliary Atresia. * **Most common indication for "Acute Liver Failure":** Acetaminophen (Paracetamol) toxicity. * **Emerging Trend:** Non-Alcoholic Steatohepatitis (NASH/NAFLD) is the fastest-growing indication for liver transplant worldwide. * **MELD Score:** Used to prioritize patients on the transplant waiting list (based on Bilirubin, Creatinine, and INR).

Question 48: What describes a reduced liver transplant?

A. Given to two recipients after dividing into two parts.
B. Left lateral lobe divided and given to a child.
C. Left lateral segment divided from segment 2 and given to a child.
D. A part of a liver segment transplanted into a recipient depending upon the requirement. (Correct Answer)

Explanation: **Explanation:** In transplant surgery, understanding the nomenclature of liver graft types is crucial for NEET-PG. **1. Why the Correct Answer is Right:** A **Reduced-size Liver Transplant (RLT)** involves taking a whole cadaveric liver and surgically downsizing it (removing specific segments) to fit a smaller recipient, typically a child. The remaining portion of the liver is discarded. The procedure is performed when a size-matched donor is unavailable, and the goal is to tailor the graft volume to the recipient's metabolic needs and anatomical space (the "part of a liver segment" refers to the specific anatomical unit required). **2. Analysis of Incorrect Options:** * **Option A:** This describes a **Split Liver Transplant**. In this procedure, one cadaveric liver is divided (usually into a right trisegment and a left lateral segment) to be transplanted into **two** different recipients. * **Option B & C:** These options describe specific technical variations of either a split or reduced transplant but are too narrow. While the left lateral segment (Segments 2 and 3) is the most common graft for pediatric recipients, the definition of a "reduced" liver is the act of downsizing the organ for a **single** recipient, regardless of which specific segments are used. **3. Clinical Pearls for NEET-PG:** * **Split Liver Transplant:** 1 Donor → 2 Recipients (Maximizes donor pool). * **Reduced Liver Transplant:** 1 Donor → 1 Recipient (Wasteful of tissue, but life-saving in emergencies). * **Living Related Liver Transplant (LRLT):** A healthy living donor gives a portion (usually the left lateral segment for a child or right lobe for an adult). * **Small-for-size Syndrome:** A complication where the graft is too small to meet the recipient's metabolic demands, leading to cholestasis and graft failure. * **Couinaud Classification:** The anatomical basis for all liver resections/transplants, dividing the liver into 8 functional segments based on vascular supply and biliary drainage.

Question 49: All are common opportunistic infections seen early in renal transplant recipients, EXCEPT:

A. Herpes virus
B. Oral candidiasis
C. Urinary tract infections
D. Nocardia (Correct Answer)

Explanation: In renal transplantation, opportunistic infections follow a predictable chronological pattern based on the level of immunosuppression. This timeline is a high-yield concept for NEET-PG. ### **Why Nocardia is the Correct Answer** Post-transplant infections are typically divided into three periods: 1. **Early (0–1 month):** Infections are usually related to surgical complications or donor/recipient-derived pathogens (e.g., UTI, wound infections, Candidiasis). 2. **Intermediate (1–6 months):** Peak immunosuppression leads to viral activations (CMV, EBV, Herpes) and opportunistic pathogens like *Pneumocystis jirovecii*. 3. **Late (>6 months):** Community-acquired infections or chronic opportunistic infections. **Nocardia** is typically a **late-onset** opportunistic infection, usually occurring **after 6 months** (often between 6–12 months) post-transplant. It presents as pulmonary cavitation, skin abscesses, or CNS involvement. ### **Analysis of Incorrect Options** * **Urinary Tract Infections (C):** These are the **most common** infections in the early period (0–1 month) due to surgical manipulation, stents, and catheters. * **Oral Candidiasis (B):** Fungal infections like Thrush are common in the first month due to high-dose induction steroids. * **Herpes Virus (A):** HSV-1 and HSV-2 reactivation typically occurs early (within the first month) due to the surgical stress and initiation of immunosuppression. ### **High-Yield Clinical Pearls** * **Most common infection overall:** Urinary Tract Infection (UTI). * **Most common viral infection (1–6 months):** Cytomegalovirus (CMV). * **Prophylaxis:** Trimethoprim-sulfamethoxazole (TMP-SMX) is used to prevent *Pneumocystis jirovecii*, but it also provides partial prophylaxis against *Nocardia* and *Toxoplasma*. * **Nocardia Triad:** Pneumonia, brain abscess, and cutaneous lesions in an immunocompromised host.

Question 50: Which of the following is an absolute contraindication for renal transplant?

A. Untreated malignancy (Correct Answer)
B. Age >65 years
C. HIV infection
D. Chronic hepatitis B or C

Explanation: **Explanation:** Renal transplantation requires lifelong potent immunosuppression to prevent graft rejection. The presence of an **untreated malignancy** is an absolute contraindication because immunosuppressive drugs inhibit the body’s immune surveillance, leading to rapid tumor progression, metastasis, and significantly increased mortality. Most guidelines require a "waiting period" (cancer-free interval) of 2 to 5 years (depending on the tumor type) before a patient can be considered for a transplant. **Analysis of Incorrect Options:** * **Age >65 years:** Advanced age is a **relative contraindication**. While elderly patients have higher surgical risks, "physiological age" is more important than chronological age. Many centers successfully transplant patients over 70 if they have a reasonable life expectancy and low cardiac risk. * **HIV Infection:** Previously an absolute contraindication, it is now a **relative contraindication**. HIV-positive patients can undergo transplantation if they have a stable CD4 count (>200 cells/µL), undetectable viral load, and no active opportunistic infections. * **Chronic Hepatitis B or C:** These are **relative contraindications**. With the advent of highly effective Direct-Acting Antivirals (DAAs) for Hep C and nucleoside analogs for Hep B, these patients can be safely transplanted and managed post-operatively. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Active infection, untreated malignancy, active substance abuse, severe uncorrectable cardiac/pulmonary disease, and non-compliance. * **Most common cause of death** after renal transplant: Cardiovascular disease. * **Most common opportunistic infection** post-transplant: CMV (Cytomegalovirus). * **Hyperacute rejection** is Type II hypersensitivity (pre-formed antibodies); **Acute rejection** is primarily Type IV (T-cell mediated).

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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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