TRANSPLANT SURGERY

Question 1 of 45
What is the most common liver disease requiring liver transplantation in the United Kingdom?

Paracetamol overdosage

Primary sclerosing cholangitis

Alcoholic liver disease

Hepatitis C virus infection

Hepatocellular carcinoma

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Question 2 of 45
A 32-year-old, blood type A positive male receives a kidney transplant from a blood type B positive female donor with
whom he had a 6-antigen HLA match. Once the kidney is anastomosed to the man's vasculature, the transplant team
immediately begins to observe swelling and interstitial hemorrhage. After the surgery, the patient developed fever and
leukocytosis and produced no urine. Which of the following is the most likely explanation?

Acute rejection due to cell mediated immunity

Acute rejection due to antibody mediated immunity

Chronic rejection due to cell mediated immunity to minor HLA mismatches

Hyperacute rejection due to preformed ABO blood group antibodies

Hyperacute rejection due to lymphocyte and macrophage infiltration

ANS:

Question 3-5 of 45
Theme: Post transplant complications

A. Renal vein thrombosis

B. Hyperacute rejection
C. Ureteric anastomotic leak
D. Renal artery thrombosis
E. Chronic allograft nephropathy
F. Lymphocele
G. Haemorrhage

Please select the most likely complication for the situation described. Each option may be used once, more than once or
not at all.

3. A 43 year old lady undergoes a live related renal transplant. Three weeks later she
presents to the clinic with swelling at the graft site and of the ipsilateral limb.Over
the last day her urine output has diminished slightly.

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4. A 44 year old lady presents to the clinic at 12 days following a renal transplant.
The operation was technically difficult. She now complains of mild swelling at the
graft site and fluid leaking from the wound. There has been a marked reduction in
urine output.

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5. A 43 year old lady is recovering from a renal transplant 3 days previously when the
team notice that she has become anuric. On examination she has a mild swelling
over the graft site and of the ipsilateral leg.

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Question 6-8 of 45
Theme: Immunosupression in transplantation
A. Azathioprine
B. Mycophenolate mofetil
C. OKT 3
D. Basiliximab
E. Cyclosporin
F. Prednisolone
G. Sirolimus
H. Tacrolimus

Please select the most appropriate immunomodulator drug for the situation described. Each option may be used once,
more than once or not at all.

6. A 40 year old man is due to have live donor related kidney transplant. Apart from a
calcineurin inhibitor and steroids which agent is most appropriate to reduce the
risk of acute graft rejection?

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7. A 42 year old lady with primary biliary cirrhosis has undergone a liver transplant
six months previously. Which drug is she most likely to be taking?

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8. Which agent has the greatest potential for myelosuppression?

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Question 9 of 45
During liver transplant surgery, anomalies of which of the following are most frequently encountered?

Anatomy of the portal vein

Anatomy of the retrohepatic vena cava

Anatomy of the caudate lobe

Anatomy of the common hepatic artery

Anatomy of the left lobe of the liver

ANS:

Question 10 of 45
A 59 year old lady has been treated for breast cancer (T2, N0, ER +ve, HER -ve) and has developed renal failure as a result
of progression of pre existing kidney disease. When could renal transplantation be considered?

1 year following completion of breast cancer treatment

3 years following completion of breast cancer treatment

5 years following completion of breast cancer treatment

Once recovered from breast cancer treatment

10 years after completion of breast cancer treatment

ANS:

Question 11 of 45
A 45 year old male has been using peritoneal dialysis with a hypertonic glucose solution for the past 4 years. Over the
past 3 months the nephrologists have noted that his dialysis has become less efficacious. What is the most likely cause?

Encapsulating peritoneal sclerosis

Development of insulinoma

Dialysate sequestration

Displaced Tenkchoff catheter

Systemic absorption of the dialysate

ANS:

Question 12 of 45
Which of the following potential organ donors would be accepted as potential brain death donors?

29 year old male suffering with new variant CJD

18 year old women with 3cm Clarks level II melanoma removed 2 years previously

28 year old female with fulminant meningococcal septicaemia

45 year old man with squamous cell carcinoma of the nose treated with excision 1 year ago

39 year old male with tuberculosis and brain injured following road traffic accident

ANS:

Question 13-15 of 45
Theme: Complications following renal transplantation

A. Lymphocele
B. Ureteric anastomotic leak
C. Renal artery stenosis
D. Renal artery thrombosis
E. Renal vein stenosis
F. Renal vein thrombosis

Please select the most likely cause for the complication described. Each option may be used once, more than once or not
at all.

13. A 43 year old man undergoes a cadaveric renal transplant with a well matched
organ. The operation is uneventful and he is recovering well on the ward with a
reasonable urine output. On the 4th post operative day he develops increasing
discomfort at the graft site and haematuria with diminished urine output. Over the
next 12 hours he becomes anuric.

ANS:

14. A 45 year old man undergoes a live donor renal transplant with a well matched
organ. The operation is uneventful and he is recovering well on the ward with a
reasonable urine output.The nursing staff are concerned because his urine output
suddenly ceases.

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15. A 47 year old lady undergoes a renal transplant from a brain dead heart beating
donor. She recovers well and is discharged home on immunosupressants. Over
the next few months she becomes progressively hypertensive and develops
proteinuria.

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Question 16 of 45
A 38 year old man in end stage renal failure resulting from polycystic kidney disease receives a cadaveric renal
transplant. Good renal function is established but four weeks later deteriorates, the serum creatinine rising by 25%. Which
of the following processes is most likely to be responsible for this deterioration?

B cell mediated rejection

Circulating immune complex disease

IgG antibody mediated rejection

Post transplant lymphoproliferative disorder

T cell mediated rejection

ANS:

Question 17 of 45
A 45 year old man has previously undergone a total liver transplant. A liver biopsy is performed and the pathologist
comments that there is paucity of bile ducts on histological examination. What is the most likely explanation?

Primary graft non function

Chronic rejection

Hyper acute rejection

Acute rejection

None of the above

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Question 18 of 45
Which of the following are absolute contraindications for liver transplantation?

HLA class 2 mismatch between donor and recipient

Cold ischaemia time of greater than 6 hours

ABO blood group mismatch between donor and recipient

HLA class 1 mismatch between donor and recipient

None of the above

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Question 19 of 45
A transplant surgeon removes a kidney for transplant from a brain dead donor. What is the best method for organ
preservation?

Infusion with heparinised ringers lactate chillled to 4 o C

Infusion with Eurocollins solution chilled to 4 o C

Infusion with heparinised ringers lactate chillled to 0 o C

Infusion with University of Winsconsin solution chillled to 4 o C

Infusion with University of Winsonsin solution chillled to 0 o C

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Question 20 of 45
Which of the anti-rejection drugs listed below is most likely to result in myelosuppression?

Prednisolone

Tacrolimus

Basiliximab

OKT 3

Azathioprine

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Question 21-23 of 45
Theme: Adverse effects of immunosupressant therapy

A
Alopecia
.
B
Hirsuitism
.
C
Leucopenia
.
D Diabetes
.
E. Diarrhoea
F. Vomiting

Please select the side effect most typically associated with the immunosupressant drugs listed below. Each option may
be used once, more than once or not at all.

21. Azathioprine

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22. Tacrolimus

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23. Cyclosporin

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Question 24 of 45
A 45 year old man is receiving tacrolimus as anti rejection therapy following a liver transplant. Which of the following
mechanisms best accounts for its therapeutic activity?

Inhibition of IL2 production by T cells via calcineurin inhibition

Inhibition of T cell production by blocking intracellular purine synthesis

Antagonism of IL2 receptor on T cells

Inhibition of the COX 2 signaling pathway and B cell activation

Suppression of bone marrow and T cell production

ANS:

Question 25 of 45
A 29 year old man receiving peritoneal dialysis develops encapsulating peritoneal sclerosis. The treating team have
become increasing concerned because he has been suffering from repeated episodes of small bowel obstruction and the
PD has become ineffective. What is the best management option?

Peritonectomy procedure

Systemic therapy with tamoxifen

Intra peritoneal chemotherapy

Total abdominal irradiation

Laparotomy and intestinal bypass

ANS:

Question 26 of 45
A 43 year old lady is noted to have chronic hydronephrosis from a transplanted renal allograft. What is the most likely
cause?

Urethral stricture

Chronic rejection

Anastomotic stricture of the ureto-vesical anastomosis

Ureteric volvulus

Atonic bladder

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Question 27 of 45
What is the most common cause of renal failure resulting in a requirement for renal transplantation?
Reflux nephropathy

Glomerulonephritis

Interstitial nephritis

Polycystic kidney disease

SLE

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Question 28 of 45
Which of the anti rejection drugs listed below is most commonly associated with cytokine release syndrome?

Prednisolone

OKT 3

Azathioprine

Mercaptopurine

Tacrolimus

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Question 29-31 of 45
Theme: Types of transplant

A. Homotopic allograft
B. Orthotopic isograft
C. Heterotopic allograft
D. Heterotopic autograft
E. Homotopic autograft
F. Homotopic xenograft
G. Heterotopic isograft
H. Heterotopic xenograft

Please select the type of transplant that most closely matches the description provided. Each option may be used once,
more than once or not at all.

29. A 34 year old lady with end stage renal failure receives a live donor renal
transplant from her identical twin sister.

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30. A 56 year old alcoholic with end stage liver failure receives a liver transplant from
an unrelated motorcyclist who is left brain dead following a road traffic accident.

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31. A 73 year old lady with aortic stenosis undergoes a aortic valve replacement with a
porcine aortic valve.

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Question 32 of 45
Which of the following patients with renal failure are most likely to require pre-transplant native organ nephrectomy?

Those with glomerulonephritis

Those with diabetes

Those with polycystic kidney disease

Those with interstitial nephritis

Those with reflux nephropathy

ANS:

Question 33 of 45
A 49 year old female is due to undergo a renal transplant. Apart from ABO compatibility which of the following is most
important in matching donor and recipient organs?

HLA-DR

Rhesus

HLA-F

HLA-G

Kidd

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Question 34 of 45
What is the most common cause of late deaths following renal transplantation?

Viral infections

Bacterial infections

Chronic graft rejection

Squamous cell cancer

Cardiovascular disease

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Question 35-37 of 45
Theme: Immunosupressant drugs

A. Tacrolimus
B. Azathioprine
C. Prednisolone
D. Basiliximab
E. Mycophenolate

Please select the immunosupressant that most closely matches the description provided. Each option may be used once,
more than once or not at all.

35. A drug that is converted to 6 mercaptopurine in the liver.

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36. A drug that inhibits IL2 production.

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37. A drug that binds to IL2 receptors.

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Question 38 of 45
A 45 year old female undergoes a cadaveric renal transplant. What is the strongest risk factor for acute graft failure?

Cold ischaemia time >24 hours

Number of HLA mismatches

Age of the recipient

Kidneys from deceased donors dying from non traumatic causes

Age of the donor

ANS:

Question 39 of 45
A 59 year old man undergoes a live donor renal transplant. In the days that follow the procedure, he is noted to have
reduced urine output, increased serum creatinine and suprapubic discomfort. Imaging with USS demonstrates a fluid
collection surrounding the graft. What is the most likely underlying cause?

Acute rejection

Lymphatic leak

Urine leak

Renal artery thrombosis

Renal vein thrombosis

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Question 40-42 of 45
Theme: Vascular causes of graft loss

A. Intimal hyperplasia
Renal artery
B.
thrombosis
C. Renal vein thrombosis
D. Atherosclerosis

Please select the most likely vascular complication for the situation described. Each option may be used once, more than
once or not at all.

40. A 56 year old male who underwent a renal transplant 4 years previously and now
presents with worsening graft function.

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41. A 43 year old male who had a renal transplant 5 months ago and now presents
with hypertension.

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42. A 38 year old male who has a sudden cessation of urine output 6 hours following
surgery.

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Question 43-45 of 45
Theme: Mode of action of immunosuppressant drugs
A
Calcineurin inhibitor
.
B
Antagonist at the IL 2 binding site of T lymphocytes
.
C
Binds to cellular glucocorticoid receptors
.
D Binds to T cell CD3 complex resulting in apoptosis of T
. cells
E. Inhibition of purine synthesis

Please select the mode of action that most closely matches each of the following immunosuppressant drugs. Each option
may be used once, more than once or not at all.

43. Azathioprine

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44. Basiliximab

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45. Tacrolimus
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