Transplant medicine Practice Questions

Q: A 58-year-old man with type 1 diabetes mellitus and end-stage renal disease on hemodialysis is being evaluated for kidney transplantation. His panel reactive antibody (PRA) level is 85%. A potential living donor kidney becomes available with a 3/6 HLA mismatch. Flow cytometry crossmatch is positive. Which immunologic intervention would be most appropriate to proceed with transplantation?

Plasmapheresis with intravenous immunoglobulin (IVIG). ***Plasmapheresis with intravenous immunoglobulin (IVIG)*** - A high **Panel Reactive Antibody (PRA)** and a **positive flow cytometry crossmatch** indicate the presence of **Donor-Specific Antibodies (DSAs)**, requiring desensitization to prevent **antibody-mediated rejection**. - **Plasmapheresis** physically removes circulating antibodies, while **IVIG** suppresses further antibody production and helps modulate the **complement system**. *Rituximab monotherapy* - While this **anti-CD20 monoclonal antibody** depletes B-cells, it is insufficient as a standalone therapy to clear existing pre-formed **DSAs**. - It is generally used as an adjunct to **plasmapheresis** rather than a primary tool for rapid desensitization in acute crossmatch-positive settings. *High-dose corticosteroids alone* - Steroids primarily target **T-cell mediated inflammation** and cytokines but do not effectively reduce the titer of pre-formed **humoral antibodies**. - Relying on steroids alone in a highly sensitized patient with a **positive crossmatch** carries an extremely high risk of **hyperacute rejection**. *Increased maintenance immunosuppression only* - Standard maintenance agents like tacrolimus and mycophenolate prevent new immune responses but cannot clear the **pre-existing antibodies** identified by the crossmatch. - Transplanting without active **antibody removal** (desensitization) ensures immediate graft failure in the presence of a positive immunologic crossmatch. *Decline transplantation and wait for better HLA match* - For highly sensitized patients (PRA >80%), waiting for a perfectly matched kidney can lead to years on dialysis with significant **morbidity and mortality**. - Though an option, **desensitization protocols** allow for successful transplantation from **living donors** when a compatible deceased donor is unlikely to be found soon.

Question 1

A 58-year-old man with type 1 diabetes mellitus and end-stage renal disease on hemodialysis is being evaluated for kidney transplantation. His panel reactive antibody (PRA) level is 85%. A potential living donor kidney becomes available with a 3/6 HLA mismatch. Flow cytometry crossmatch is positive. Which immunologic intervention would be most appropriate to proceed with transplantation?

Accepted Answer

Plasmapheresis with intravenous immunoglobulin (IVIG)

Answer

Rituximab monotherapy

Answer

High-dose corticosteroids alone

Answer

Increased maintenance immunosuppression only

Answer

Decline transplantation and wait for better HLA match

Question 2

A 45-year-old woman with end-stage liver disease due to primary sclerosing cholangitis undergoes orthotopic liver transplantation. On postoperative day 3, she develops fever (38.9°C), tachycardia, and increased abdominal pain. Laboratory studies show: AST 850 U/L, ALT 920 U/L, total bilirubin 4.2 mg/dL, alkaline phosphatase 380 U/L. Doppler ultrasound shows absent flow in the hepatic artery. What is the most appropriate next step in management?

Accepted Answer

Immediate surgical exploration for hepatic artery thrombosis

Answer

Percutaneous transhepatic cholangiography

Answer

Increase immunosuppression to prevent rejection

Answer

Start broad-spectrum antibiotics for cholangitis

Answer

Continue observation with serial liver function tests

Transplant medicine — MCQs

Transplant medicine — MCQs

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