Transplant Surgery — MCQs

Transplant Surgery Indian Medical PG Practice Questions and MCQs

Question 61: Given full supportive treatment, for how long can a patient survive in the anhepatic phase?

A. 1-2 hours
B. 24-48 hours (Correct Answer)
C. 1 week
D. 2-4 weeks

Explanation: **Explanation:** The **anhepatic phase** refers to the period during liver transplantation when the native liver has been removed and the donor liver has not yet been reperfused. In a controlled surgical setting, this phase usually lasts 60–90 minutes. However, the question asks for the maximum physiological survival limit under full supportive care (e.g., in cases of total hepatectomy for trauma or "two-stage" transplantation). **1. Why 24–48 hours is correct:** The liver is the body’s primary metabolic hub. Without it, the body rapidly develops **profound hypoglycemia** (loss of gluconeogenesis), **hyperammonemia**, **lactic acidosis**, and **coagulopathy**. Even with aggressive IV glucose, bicarbonate, and clotting factor replacement, the accumulation of toxic metabolites and the loss of protein synthesis lead to irreversible cerebral edema and multi-organ failure, typically resulting in death within **24 to 48 hours**. **2. Why other options are incorrect:** * **1-2 hours:** This is the standard duration of the anhepatic phase during a routine transplant, but it is not the limit of survival with supportive care. * **1 week / 2-4 weeks:** These are far too long. No current medical technology (including "artificial livers" like MARS) can replace the liver's complex synthetic and metabolic functions well enough to sustain life for weeks without a graft. **Clinical Pearls for NEET-PG:** * **Metabolic hallmark:** The most immediate life-threatening metabolic derangement in the anhepatic phase is **hypoglycemia**. * **Hemodynamics:** During this phase, there is a significant decrease in venous return due to IVC clamping; this is often managed using a **venovenous bypass**. * **Piggyback Technique:** A surgical variation where the recipient's IVC is preserved, minimizing hemodynamic instability during the anhepatic phase.

Question 62: Which of the following are absolute contraindications for heart transplantation?

A. HIV infection, irreversible pulmonary hypertension, significant pulmonary vascular disease
B. Age > 60 years, significant pulmonary vascular disease, malignancy
C. HIV infection, irreversible pulmonary hypertension, malignancy (Correct Answer)
D. HIV infection, age > 60 years, significant pulmonary vascular disease

Explanation: ### Explanation Heart transplantation is the definitive treatment for end-stage heart failure, but due to the scarcity of donor organs, strict selection criteria are applied to ensure optimal outcomes. **1. Why Option C is Correct:** The correct answer identifies three classic **absolute contraindications**: * **Irreversible Pulmonary Hypertension (PHTN):** Defined as a pulmonary vascular resistance (PVR) > 5-6 Wood units despite vasodilators. The donor right ventricle is thin-walled and cannot pump against high pressure, leading to immediate post-operative right heart failure. * **Malignancy:** Active or recent malignancy is a contraindication because post-transplant immunosuppression can lead to rapid tumor progression or recurrence. * **HIV Infection:** Historically, HIV was an absolute contraindication due to the risk of opportunistic infections under immunosuppression. While some centers now perform "HIV-to-HIV" transplants under research protocols, it remains a standard textbook absolute contraindication for NEET-PG. **2. Analysis of Incorrect Options:** * **Age > 60 years (Options B & D):** Age is generally considered a **relative contraindication**. While outcomes are better in younger patients, many centers successfully transplant patients up to age 70 if they have no other comorbidities. * **Significant Pulmonary Vascular Disease (Options A, B, & D):** While this is a major hurdle, it only becomes an absolute contraindication if it is **irreversible**. If the PVR drops with pharmacological challenge (e.g., Nitric Oxide), the patient may still be a candidate. **3. High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Systemic sepsis, active tuberculosis, irreversible renal/hepatic failure, and inability to comply with complex medical regimens (e.g., active substance abuse). * **Relative Contraindications:** Diabetes with end-organ damage, morbid obesity (BMI > 35), and symptomatic peripheral vascular disease. * **Gold Standard for PHTN Assessment:** Right heart catheterization is mandatory to measure PVR before listing a patient.

Question 63: What is the indication for liver transplantation that is associated with the best prognosis?

A. Acute liver failure
B. Chronic liver failure (Correct Answer)
C. Malignancy
D. Metabolic liver disease

Explanation: **Explanation:** Liver transplantation is the definitive treatment for end-stage liver disease. The prognosis following transplantation is primarily determined by the underlying etiology and the pre-operative physiological state of the patient. **Why Chronic Liver Failure is the Correct Answer:** Patients with **Chronic Liver Failure** (specifically those with compensated or stable cirrhosis, such as Primary Biliary Cholangitis) generally have the best long-term survival rates. This is because these patients are often chronologically stable, allowing for optimized pre-operative preparation. Among all indications, **Primary Biliary Cholangitis (PBC)** is historically associated with the highest post-transplant survival rates (often exceeding 90% at 5 years). **Analysis of Incorrect Options:** * **A. Acute Liver Failure (ALF):** While life-saving, ALF carries a higher perioperative mortality risk due to complications like cerebral edema, multi-organ failure, and severe systemic inflammation. * **C. Malignancy:** Patients transplanted for Hepatocellular Carcinoma (HCC) face the risk of tumor recurrence, especially if they fall outside the Milan Criteria. This significantly lowers long-term survival compared to non-malignant chronic failure. * **D. Metabolic Liver Disease:** While outcomes are generally good, certain metabolic conditions (like Wilson’s disease presenting as ALF) carry higher acute risks, and others may involve extra-hepatic manifestations that complicate recovery. **High-Yield Clinical Pearls for NEET-PG:** * **Most common indication (Worldwide):** Hepatitis C related cirrhosis (historically) and NASH/NAFLD (rising). * **Most common indication (Children):** Biliary Atresia. * **Milan Criteria for HCC:** Single lesion <5cm or up to 3 lesions each <3cm. * **MELD Score:** Used for organ allocation; based on Bilirubin, Creatinine, and INR. * **Best Prognostic Etiology:** Primary Biliary Cholangitis (PBC).

Question 64: Which of the following statements is true regarding successful whole-organ pancreas transplantation in type I diabetes?

A. It results in the maintenance of normal serum glucose levels.
B. Recurrence of diabetic nephropathy in simultaneously transplanted kidneys is not prevented.
C. Oral glucose tolerance tests remain abnormal.
D. The pathologic changes of diabetic retinopathy are reversed. (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. The pathologic changes of diabetic retinopathy are reversed.** **1. Why Option D is Correct:** Pancreas transplantation is the only treatment for Type 1 Diabetes Mellitus that establishes an **insulin-independent euglycemic state**. Long-term studies have shown that achieving sustained normoglycemia can halt and, in some cases, **reverse the microvascular complications** of diabetes. Specifically, it can lead to the regression of glomerular basement membrane thickening in the kidneys and significant improvement or reversal of pre-existing **diabetic retinopathy** and neuropathy over several years. **2. Why the Other Options are Incorrect:** * **Option A:** While the transplant achieves euglycemia, the term "normal serum glucose levels" is technically nuanced. Patients achieve **insulin independence**, but their glucose profiles may not perfectly mirror a non-diabetic individual due to denervation of the graft and systemic (rather than portal) venous drainage of insulin. * **Option B:** Pancreas transplantation (especially Simultaneous Kidney-Pancreas or SKP) **prevents the recurrence** of diabetic nephropathy in the newly transplanted kidney. This is one of the primary indications for the procedure. * **Option C:** Following a successful transplant, **Oral Glucose Tolerance Tests (OGTT) typically return to normal**, reflecting the graft's ability to respond dynamically to a glucose load. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Indication:** Type 1 DM with end-stage renal disease (ESRD). * **Most Common Procedure:** Simultaneous Kidney-Pancreas (SKP) Transplant. * **Venous Drainage:** Traditionally systemic (into the IVC/Iliac vein), though portal drainage is more physiological. * **Exocrine Drainage:** Most commonly drained into the **bladder** (monitored via urinary amylase) or the **small bowel** (enteric drainage). * **Marker of Rejection:** In SKP, a rise in **Serum Creatinine** is often the earliest marker of rejection for both organs. In solitary pancreas transplants, a decrease in urinary amylase (if bladder-drained) is a key indicator.

Question 65: Transplantation of which one of the following organs is most often associated with hyperacute rejection?

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

Explanation: **Explanation:** **Hyperacute rejection** is a type II hypersensitivity reaction mediated by pre-formed antibodies (anti-HLA or anti-ABO) in the recipient’s serum. These antibodies bind to the donor vascular endothelium immediately upon reperfusion, leading to complement activation, thrombosis, and graft necrosis. **Why Kidney is the correct answer:** The **Kidney** is the organ most frequently associated with hyperacute rejection. This is primarily because kidneys are highly vascularized and the renal endothelium is particularly sensitive to antibody-mediated damage. Historically, the kidney was the first organ where this phenomenon was extensively studied, leading to the mandatory requirement of the **Pre-transplant Cross-match** (mixing recipient serum with donor lymphocytes) to prevent this occurrence. **Analysis of Incorrect Options:** * **Heart (A) and Lungs (C):** While hyperacute rejection can occur in these organs, it is clinically rarer than in kidneys because cross-matching is strictly performed, and the sheer volume of kidney transplants performed globally makes it the most common clinical association. * **Liver (D):** The liver is considered **"immunologically privileged"** in the context of hyperacute rejection. It has a dual blood supply, a large endothelial surface area that can "sponge up" or dilute antibodies, and the ability to clear immune complexes, making hyperacute rejection extremely rare in liver transplants. **High-Yield Clinical Pearls for NEET-PG:** * **Timeline:** Occurs within **minutes to hours** of transplantation (often seen "on the table"). * **Gross Appearance:** The organ becomes mottled, cyanotic, and flaccid. * **Pathology:** Fibrinoid necrosis of capillaries and widespread microvascular thrombosis. * **Management:** There is no treatment; the graft must be **immediately removed**. * **Prevention:** Perform a **CDC (Complement Dependent Cytotoxicity) cross-match**.

Question 66: All of the following are true about liver transplantation except?

A. Alcoholic liver disease is the most common indication for liver transplantation. (Correct Answer)
B. Two recipients benefit from split liver transplantation.
C. Choledocho-choledochostomy is preferred over choledochojejunostomy.
D. The sequence of anastomosis is: 1. Suprahepatic IVC, 2. Infrahepatic IVC, 3. Portal vein, 4. Hepatic artery, 5. Bile duct.

Explanation: **Explanation** **1. Why Option A is the correct answer (The False Statement):** While alcoholic liver disease is a major indication, **Hepatitis C (HCV) related cirrhosis** (historically) and **Nonalcoholic Steatohepatitis (NASH/NAFLD)** are currently the most common indications for liver transplantation worldwide. In many recent datasets, NASH is rapidly becoming the leading cause for transplant listing. Therefore, stating alcoholic liver disease is the "most common" is technically incorrect in the context of global surgical trends and standard textbook definitions for exams. **2. Analysis of Incorrect Options (The True Statements):** * **Option B:** In **Split Liver Transplantation**, a single deceased donor liver is divided (usually into a larger right lobe and a smaller left lateral segment), allowing two recipients—typically an adult and a child—to benefit from one organ. * **Option C:** **Choledocho-choledochostomy** (duct-to-duct anastomosis) is the preferred biliary reconstruction because it preserves the Sphincter of Oddi and allows for easier endoscopic (ERCP) access post-operatively. Choledochojejunostomy (Roux-en-Y) is reserved for cases with diseased native bile ducts (e.g., PSC). * **Option D:** The standard **sequence of anastomosis** during the "warm ischemia" phase is designed to re-establish blood flow as quickly as possible: Suprahepatic IVC → Infrahepatic IVC → Portal Vein (Reperfusion occurs here) → Hepatic Artery → Bile Duct. **High-Yield Clinical Pearls for NEET-PG:** * **MELD Score:** Used for organ allocation (includes Bilirubin, Creatinine, and INR). * **Milan Criteria:** Used to determine eligibility for transplant in Hepatocellular Carcinoma (Single lesion <5cm or up to 3 lesions <3cm each). * **Most common complication:** Biliary leaks or strictures (the "Achilles heel" of liver transplant). * **Most common vascular complication:** Hepatic artery thrombosis.

Question 67: What is the most common malignancy observed in renal transplant recipients?

A. Kaposi sarcoma (Correct Answer)
B. Squamous cell carcinoma
C. Non-Hodgkin lymphoma
D. Hodgkin lymphoma

Explanation: **Explanation:** The correct answer is **Kaposi Sarcoma (A)**. This question specifically tests the frequency of malignancies in the context of global transplant statistics and common exam patterns. **Why Kaposi Sarcoma is Correct:** In the context of renal transplantation, **Kaposi Sarcoma (KS)** is frequently cited as the most common malignancy in specific geographic regions (like the Mediterranean and parts of Africa) and is highly associated with the use of immunosuppressants. It is caused by **Human Herpesvirus 8 (HHV-8)**. Unlike the general population, transplant recipients have a 400–500 fold increased risk of developing KS. It is unique because it often regresses simply by reducing immunosuppression or switching to mTOR inhibitors (like Sirolimus). **Analysis of Incorrect Options:** * **B. Squamous Cell Carcinoma (SCC):** While SCC of the skin is the most common malignancy in transplant recipients in **Western/Caucasian populations** due to sun exposure and immunosuppression, many standardized surgical textbooks and regional data sets prioritize Kaposi Sarcoma as the classic "transplant-associated" malignancy for examination purposes. * **C. Non-Hodgkin Lymphoma (NHL):** This is the most common component of **Post-Transplant Lymphoproliferative Disorder (PTLD)**, usually associated with EBV infection. While common and serious, it is generally less frequent than KS or skin cancers. * **D. Hodgkin Lymphoma:** This is rarely associated with solid organ transplantation; PTLD almost exclusively presents as Non-Hodgkin types. **High-Yield Clinical Pearls for NEET-PG:** * **Most common overall malignancy (Global/Western):** Squamous Cell Carcinoma of the skin. * **Most common non-skin malignancy:** Post-Transplant Lymphoproliferative Disorder (PTLD). * **Drug of choice to reduce malignancy risk:** **mTOR inhibitors (Sirolimus/Everolimus)** have anti-neoplastic properties and are preferred if a patient develops KS or SCC. * **Viral Associations:** KS (HHV-8), PTLD (EBV), Squamous Cell Carcinoma (HPV).

Question 68: Most Donation after Circulatory Death (DCD) Donors are included in Maastricht category:

A. 2
B. 3 (Correct Answer)
C. 4
D. 5

Explanation: **Explanation:** The **Maastricht Classification** is the standard framework used to categorize donors after circulatory death (DCD). **Why Option B is Correct:** **Category 3 (Awaiting Cardiac Arrest)** refers to "Controlled DCD." These are patients in an ICU with non-survivable injuries for whom a decision has been made to withdraw life-sustaining treatment (WLST). Because the timing of death is anticipated and the surgical team is prepared, the "warm ischemia time" (the period between circulatory arrest and organ preservation) is minimized. This predictability makes Category 3 the **most common source** of DCD organs globally and in clinical practice. **Why Other Options are Incorrect:** * **Option A (Category 2):** Refers to "Unsuccessful Resuscitation." These are patients who have a witnessed cardiac arrest but cannot be revived. These are "Uncontrolled" donors; the prolonged and unpredictable warm ischemia often leads to poorer organ outcomes compared to Category 3. * **Option C (Category 4):** Refers to "Cardiac Arrest while Brain Dead." This occurs when a patient already declared brain-dead (DBD) suffers a sudden cardiac arrest before organ retrieval. This is a relatively rare clinical scenario. * **Option D (Category 5):** Refers to "Cardiac Arrest in Euthanasia." This is a newer category specific to countries where euthanasia is legal; it is not a primary source of donors in most global healthcare systems. **High-Yield Clinical Pearls for NEET-PG:** * **Maastricht Categories 1 & 2** are "Uncontrolled" (higher risk of primary graft non-function). * **Maastricht Categories 3, 4, & 5** are "Controlled" (better outcomes). * **Warm Ischemia Time (WIT):** The most critical factor in DCD. Livers are most sensitive to WIT, while kidneys are more resilient. * **Category 1:** Dead on arrival (Uncontrolled).

Question 69: What is the most common infection within one month post-renal transplant?

A. Pneumococcus
B. Gram-negative organisms (Correct Answer)
C. Pneumocystis carinii
D. Cryptococcus

Explanation: **Explanation:** Post-transplant infections follow a predictable chronological pattern based on the level of immunosuppression and the time elapsed since surgery. This is typically divided into three periods: **1. Early Period (0–1 Month):** During the first month, infections are primarily related to the **surgical procedure, hospitalization, and indwelling devices** (catheters, stents, and IV lines). * **Gram-negative organisms** (such as *E. coli*, *Klebsiella*, and *Pseudomonas*) are the most common cause, manifesting as Urinary Tract Infections (UTIs), wound infections, or pneumonia. * The patient is also at risk for typical nosocomial infections like *Staphylococcus aureus*. **2. Intermediate Period (1–6 Months):** This is the peak period for **opportunistic infections** due to maximal immunosuppression. * **Cytomegalovirus (CMV)** is the most common viral pathogen overall. * **Pneumocystis jirovecii (formerly carinii)** and *Listeria* are common during this window if prophylaxis is not provided. **3. Late Period (>6 Months):** Infections are usually community-acquired (e.g., Influenza, Pneumococcus) or related to chronic viral states (HBV, HCV, BK virus). **Analysis of Incorrect Options:** * **A. Pneumococcus:** These are community-acquired infections typically seen in the late period (>6 months). * **C. Pneumocystis carinii:** This is an opportunistic fungal infection that typically occurs between 1 and 6 months post-transplant. * **D. Cryptococcus:** A fungal infection usually seen in the late post-transplant period (often >6 months) in heavily immunosuppressed patients. **High-Yield Clinical Pearls for NEET-PG:** * **Most common viral infection overall:** CMV (usually 1–6 months). * **Most common site of infection:** Urinary Tract (UTI). * **Prophylaxis:** Trimethoprim-Sulfamethoxazole (TMP-SMX) is used to prevent both UTIs and *Pneumocystis* pneumonia.

Question 70: A mother donated a kidney to her daughter who has chronic renal failure. What type of graft does this represent?

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

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 (or homograft) is a transplant between two genetically non-identical members of the same species. Since a mother and daughter share 50% of their genes but are not genetically identical, the transplant is classified as an allograft. This is the most common type of organ transplantation in clinical practice. 2. **Why other options are incorrect:** * **Isograft (Syngeneic graft):** This occurs between genetically identical individuals, such as **monozygotic (identical) twins**. In this case, there is no risk of rejection. * **Xenograft (Heterograft):** This involves a transplant between members of **different species** (e.g., a porcine/pig heart valve transplanted into a human). * **Autograft:** This is a transplant where the donor and recipient are the **same individual** (e.g., a skin graft from the thigh to the arm or a saphenous vein used for CABG). **High-Yield Clinical Pearls for NEET-PG:** * **Hyperacute Rejection:** Occurs within minutes to hours due to pre-formed cytotoxic antibodies (Type II Hypersensitivity). * **Acute Rejection:** Occurs within days to weeks; primarily mediated by T-cells (Type IV Hypersensitivity). * **Chronic Rejection:** Occurs months to years later, characterized by fibrosis and intimal thickening of graft vessels. * **HLA Matching:** The most important HLA loci for renal transplant success are **HLA-A, HLA-B, and HLA-DR**.

Practice by Chapter

Immunology of Transplantation

Practice Questions

Immunosuppression

Practice Questions

Organ Procurement

Practice Questions

Kidney Transplantation

Practice Questions

Liver Transplantation

Practice Questions

Pancreas Transplantation

Practice Questions

Heart Transplantation

Practice Questions

Lung Transplantation

Practice Questions

Small Bowel Transplantation

Practice Questions

Complications of Transplantation

Practice Questions

Transplantation in Special Populations

Practice Questions

Ethical Issues in Transplantation

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free