TRANSPLANTATION SURGERY Multiple Choice Questions :-
1. The “father of experimental surgery” who performed pioneering research, including several transplantation procedures, was:
A. Homer, the Greek who described the Chimaera in his Iliad.
B. Gasparo Tagliacozzi, the Italian who described a method of reconstructing the nose.
C. John Hunter, the Scot who performed autografts and xenografts.
D. Emrick Ullmann, the Austrian who performed the first successful renal allograft.
E. Alexis Carrel, the Franco-American who described a successful technique for vascular anastomosis.
2. Transplantation terminology contains terms to describe the relationship of the graft donor to the graft recipient. Historical terms such as “homograft” and “heterograft” have been replaced by less ambiguous terms. The correct modern terminology for a graft between genetically nonidentical members of the same species is:
A. Allogeneic graft.
B. Autogeneic graft.
C. Isogeneic graft.
D. Syngeneic graft.
E. Xenogeneic graft.
3. The modern era of clinical organ transplantation began with the advent of chemical immunosuppression. The important discovery that produced the initial success of cadaveric transplantation was:
D. Antilymphocyte serum.
E. Monoclonal antibody OKT3.
4. Which of the following statements correctly characterize the genetic basis of histocompatibility?
A. Histocompatibility is determined by a series of genes inherited as a complex and subject to the mendelian rules that characterize recessive traits.
B. Histocompatibility depends in part on the inheritance of histocompatibility genes and in part on the inheritance of T-cell receptor genes.
C. Major histocompatibility genes are polymorphic.
D. Histocompatibility genes are independently segregating and co-dominant.
E. Histocompatibility is learned.
5. The major histocompatibility complex (MHC) includes genes that encode which of the following proteins?
6. Which of the following distinguish MHC class I from MHC class II antigens?
A. MHC class I and class II antigens are encoded in different regions of the MHC complex.
B. MHC class I antigens are expressed on specialized antigen-presenting cells, whereas MHC class II antigens are expressed on all cells.
C. MHC class I and class II are members of different supergene families.
D. MHC class I are considered to be the major histocompatibility antigens and MHC class II the minor histocompatibility antigens.
E. MHC class I is recognized by the CD8 glycoprotein, whereas MHC class II is recognized by the CD4 glycoprotein.
7. Which of the following characterize the role of the major histocompatibility antigens in immune responses?
A. The major histocompatibility antigens are critical in antigen processing and presentation.
B. Major histocompatibility antigens contribute to the maturation of T cells in the thymus.
C. T cells recognize only foreign antigens that are complexed with major histocompatibility antigens.
D. Expression of major histocompatibility antigens is increased in inflammation.
E. Recognition of major histocompatibility antigens is critical to the development of tolerance.
8. The unusual intensity of alloimmune responses reflects which of the following characteristics?
A. The presence of a peptide-binding groove in the MHC molecule.
B. Recognition of the native structure of allogeneic MHC molecules.
C. The high frequency of T cells able to recognize directly allogeneic MHC antigens.
D. Stimulation of many T-cell receptors during the interaction of a T cell with an antigen-presenting cell.
E. The high frequency of antigen-presenting cells able to be recognized by T cells.
9. Which of the following statements correctly characterize the role of histocompatibility typing in transplantation?
A. Histocompatibility typing must be carried out before transplantation can safely be undertaken.
B. The “rules” of histocompatibility were established shortly after the advent of immunosuppressive therapy made transplantation feasible.
C. Histocompatibility typing may involve serologic, cellular, and molecular procedures for typing.
D. The role of histocompatibility matching in transplantation is controversial.
E. The cross-match test is carried out to determine whether a potential graft recipient has antibodies against the donor.
10. Activation of T cells requires:
A. Stimulation of the antigen receptor.
B. Stimulation of the MHC antigen.
11. Which of the following statements characterize the biology of allotransplantation?
A. The rejection response is systemic.
B. The rejection response is learned.
C. The rejection response involves a constellation of immunologic and environmental factors.
D. Allotransplantation evokes a cellular immune response.
E. Allotransplantation evokes a humoral immune response.
12. Allograft rejection may involve which of the following?
A. Helper T cells.
B. Veto cells.
E. The Arthus reaction.
13. Which of the following statements about allograft rejection are true?
A. In the absence of immunosuppression, the time and intensity of rejection of transplants between unrelated donors and recipients is highly variable.
B. Allograft rejection may be mediated by antibodies or by cells.
C. Allograft rejection is thought to be caused by Th2 cells.
D. Acute cellular rejection is the major cause for loss of clinical organ transplants.
E. An individual with “tolerance” is unable to reject an allograft.
14. The presence of donor-reactive lymphocytotoxic antibodies in the serum of a potential kidney transplant recipient:
A. Can be detected by in vitro testing with recipient leukocytes and donor serum.
B. Is a contraindication to kidney transplantation.
C. Can be found in all male patients older than 20 years.
15. Utilization of a living related donor instead of a cadaver donor is no longer an advantage in renal transplantation because:
A. Public recognition of transplantation as a successful therapy has facilitated obtaining family permission for recovery of transplantable organs. Thus, because sufficient kidneys are available from “brain-dead” accident victims, there is no need to use related donors.
B. Cyclosporine therapy after cadaveric renal transplants has improved their outcome, which is now comparable to related-donor transplants.
C. Modern preservation techniques can maintain viability of kidneys from cadaver donors for many hours, consistently allowing their early function to be as good as that of kidneys from living donors.
D. None of the above.
16. Large volumes of urine in the early postoperative course of renal transplant patients:
A. Result from osmotic stimuli to diuresis.
B. May signify reversible polyuric acute tubular necrosis.
C. Should be replaced by administration of equal volumes of crystalloid.
D. Facilitate the diagnosis of rejection and obstruction of the renal artery and/or collecting system.
17. As compared with the early immunosuppressive (azathioprine, steroids, antilymphocyte serum) some newer agents have the following specific advantages:
A. Cyclosporine, which interferes with lymphokine production, exhibits neither bone marrow nor renal toxicity.
B. Monoclonal antibody (OKT3) is more available and has greater specificity and fewer side effects than antilymphocyte serum.
C. Tacrolimus (FK506) has properties similar to those of cyclosporine but is especially valuable for rescue of grafts that are failing on cyclosporine therapy.
D. None of the above.
18. Survival rates for patients on dialysis are better than those for patients receiving renal allografts in the following circumstances:
A. A living related donor is available.
B. A cadaver donor must be used.
C. The recipient’s renal failure is secondary to diabetes.
D. None of the above.
19. Posttransplantation hypertension can be caused by:
B. Cyclosporine nephrotoxicity.
C. Renal transplant artery stenosis (RTAS).
D. Recurrent disease in the allograft.
20. Which of the following statements about posttransplantation malignancy is correct?
A. Certain immunosuppressive agents increase the incidence of malignancy in transplant recipients, whereas others do not.
B. Those malignancies most commonly seen in the general population (breast, colon) are substantially more common in transplant recipients.
C. Lymphoproliferative states and B-cell lymphomas are associated with Epstein-Barr virus.
D. None of the above.
21. One week after receiving a cadaver renal allograft, the recipient remains oliguric and dialysis dependent. Ultrasonography reveals a larger perigraft fluid collection. Your next step in management includes:
A. No further investigations (since perigraft collections are fairly common after renal transplantation).
B. Aspiration of the perigraft fluid collection and instillation of a fibrosis-inducing agent to obliterate the dead space.
C. Angiography for localization of a bleeding site in the renal allograft.
D. Aspiration of the perigraft fluid collection for chemical analysis.
22. Regarding access for hemodialysis, which of the following statements is/are incorrect?
A. Some patients are not candidates for hemodialysis.
B. Some complications can lead to exsanguination.
C. The best access to place for a patient beginning dialysis is a leg polytetrafluoroethylene (PTFE) graft from the femoral artery to the saphenous vein.
D. First of all one should attempt to create a Brescia-Cimino fistula.
E. The leading complication of PTFE grafts is infection.
23. Access to the peritoneal cavity for peritoneal dialysis can be gained:
C. Using laparoscopy.
D. Only using general anesthesia.
24. Which of the following are true concerning immunosuppression?
A. Current immunosuppressive agents function in a nonspecific manner to suppress rejection.
B. The use of immunosuppressive agents is associated with an increased rate of opportunistic infections.
C. An increased rate of malignancy is not associated with the use of immunosuppressive agents.
D. In almost all cases, the graft is rejected if immunosuppression is discontinued.
25. Which of the following is true for hyperacute rejection?
A. It is mediated by preformed cytotoxic antibody.
B. It occurs late in the life of the graft.
C. It is usually reversible with a bolus of steroids.
D. None of the above.
26. The major components of the immune system include which of the following?
A. T lymphocytes.
B. B lymphocytes.
27. The most common types of immunosuppressive agents used clinically include which of the following?
B. Alkylating agents.
C. Inhibitors of helper T-cell activation.
E. Lymphocyte depletion compounds.
28. Which of the following is/are true of the antiproliferative agents?
A. They act by preventing the differentiation and division of the immunocompetent lymphocyte after it encounters antigen.
B. The antimetabolites in this group have a structural similarity to cell metabolites and either inhibit enzymes of a metabolic pathway or are incorporated during synthesis to produce faulty molecules.
C. The most frequently used antiproliferative agent is azathioprine.
29. Which of the following is the one true statement about acute rejection.
A. Acute rejection is mediated by T lymphocytes.
B. Acute rejection is mediated by preformed cytotoxic antibody.
C. Acute rejection most frequently occurs over months.
30. Which of the following are true of cyclosporine?
A. It was the first immunosuppressive agent to be used clinically.
B. It acts selectively on T cells to suppress rejection.
C. Toxic effects include hirsutism, hypertension, nephrotoxicity, and increased risk of opportunistic infections.
31. Which of the following are true of OKT3?
A. It is not a monoclonal antibody.
B. It binds to the T-cell receptor and inactivates T-cell function.
C. It is the monoclonal antibody most frequently used in clinical transplantation.
32. Hypothermia (0? to 4? C) is a critical component of successful organ cold storage because:
A. Oxygen is more soluble in cold solutions and provides a continual supply for energy metabolism.
B. There is no way to suppress microbial growth except by cooling and slowing the growth rate.
C. Hypothermia diminishes energy requirements and allows the limited energy reserve to keep the organ alive.
D. It slows metabolism and the enzymic processes that would destroy the cell.
33. Is the following statement true or false? Organs should be preserved only for short periods of time (4 to 8 hours) because longer periods lead to too many complications, and even loss of the organ.
34. Which of the following statements about hepatic artery thrombosis following liver transplantation is/are correct?
A. Thrombosis of the hepatic artery following liver transplantation is more common in children than in adult patients.
B. Thrombosis of the hepatic artery usually occurs several weeks after transplant as a result of arteriosclerosis.
C. Thrombosis of the hepatic artery in the early days following transplantation is a serious complication leading to death unless retransplantation can be performed within 36 to 72 hours.
D. Late thrombosis of the hepatic artery may present as biliary complication or intrahepatic abscesses.
E. Thrombosis of the portal vein is more frequent than hepatic artery thrombosis following liver transplantation.
35. Which of the following statements about fulminant hepatic failure (FHF) is/are correct?
A. Fulminant hepatic failure can occur in the setting of pre-existing chronic liver disease.
B. Coagulopathy and coma are important findings in patients with FHF.
C. Liver transplant should not be attempted in patients with FHF because of the high mortality rate, regardless of the treatment used.
D. The main cause of death in these patients is cerebral edema.
E. One of the most important factors in prognosis of FHF is the cause of liver disease.
36. Which of the following statements about immunology in liver transplantation is/are correct?
A. Good human leukocyte antigen (HLA) matching between recipient and donor is mandatory for a good outcome for liver transplantation.
B. Hyperacute rejection is almost nonexistent following liver transplantation.
C. Acute rejection occurs in more than 50% of patients and is reversible in most patients with large doses of steroids.
D. Acute rejection is very rare later than 2 months after liver transplantation unless the patient is inadequately immunosuppressed.
E. Chronic rejection is different from acute rejection, is usually irreversible, and often requires retransplantation.
37. An elevated serum amylase level following pancreas-kidney transplantation may be due to:
A. Preservation/procurement injury.
C. Reflux pancreatitis.
D. Duodenal segment leak or bladder leak.
E. Native pancreatitis.
38. Complications of a pancreas transplant drained into the bladder include:
A. Duodenal segment leak.
B. Recurrent urinary tract infections.
C. Recurrent hematuria.
E. Refractory loss of bicarbonate.
39. Patient selection criteria for simultaneous pancreas-kidney transplantation should include:
A. Type I diabetes mellitus.
B. Type II diabetes mellitus.
C. Dialysis dependence.
D. Renal dysfunction with a creatinine value greater than 3.0.
E. Minimal extrarenal morbidity related to diabetes.
40. Criteria for a pancreas donor include:
A. No history of diabetes.
B. No liver donation.
C. No replaced hepatic artery vessels arising from the superior mesenteric artery (SMA).
D. No previous splenectomy.
E. No pancreatitis.
41. For which of the following clinical scenarios would cardiac transplantation be an appropriate therapeutic modality?
A. A 50-year-old man with angina pectoris, three-vessel coronary artery disease, and a left ventricular ejection fraction of 25%.
B. A 75-year-old woman with irremediable heart failure secondary to critical aortic stenosis.
C. A 25-year-old male athlete with insidious onset of heart failure secondary to idiopathic dilated cardiomyopathy.
D. A 55-year-old woman who is status post two previous surgeries for coronary artery revascularization, now presenting with heart failure in the absence of angina, left ventricular ejection fraction of 15%, and insufficient target coronary arteries for a third bypass procedure.
E. A newborn infant with hypoplastic left heart syndrome and no other congenital anomalies.
F. A 30-year-old woman who develops irremediable heart failure due to postpartum cardiomyopathy after giving birth.
42. Suitable donors for heart transplantation have which of the following characteristics?
A. Normal electrocardiogram (ECG).
B. Normal echocardiogram.
C. Positive serology for HIV or hepatitis B or C.
D. Patient requiring high-dose epinephrine to maintain a systolic blood pressure of 90 mm. Hg.
E. Age over 70 years.
43. Heart-lung transplant is currently the therapy of choice for which of the following conditions?
A. Primary pulmonary hypertension with reasonably well-preserved right ventricular function.
B. Eisenmenger’s syndrome due to single ventricle and truncus arteriosus.
C. Validated cardiomyopathy in a patient with cystic fibrosis and end-stage lung disease.
D. Cystic fibrosis and end-stage lung failure with normal heart function.
E. Eisenmenger’s syndrome due to an atrial septal defect.
F. End-stage lung disease secondary to emphysema.
44. Both single and bilateral lung transplantation are suitable technical alternatives for which of the following conditions?
A. Obstructive lung disease (chronic obstructive pulmonary disease, emphysema).
B. Restrictive lung disease (pulmonary fibrosis).
C. Primary pulmonary hypertension.
D. Cystic fibrosis.
45. Which of the following are contraindications to lung transplantation?
A. Age 65 years or older.
B. Current corticosteroid therapy.
C. History of thoracotomy.
D. Ventilator-dependent respiratory failure.
46. Which of the following is the single most useful approach for diagnosing acute lung allograft rejection?
A. Clinical diagnosis.
B. Decline in spirometry and oxygenation.
C. Chest radiographic abnormalities.
D. Fiberoptic bronchoscopy with transbronchial lung biopsy.
47. Advantages of split-thickness skin grafts over full-thickness skin grafts include:
A. Split-thickness grafts include only part of the epidermis and none of the dermis.
B. Split-thickness grafts offer better pigment matching.
C. Split-thickness grafts offer better resistance to contraction.
D. Split-thickness grafts offer better resistance to infection.
E. Split-thickness grafts survive better on surfaces with compromised blood supply.
48. The most commonly used substitutes for peripheral arteries are:
A. Dacron grafts.
B. Expanded polytetrafluoroethylene (Gore-Tex) grafts.
C. Internal, external, and/or common iliac artery autografts.
D. Bovine carotid artery xenografts.
E. Saphenous vein autografts.
49. Endocrine autografts were among the first successful transplantation procedures. The demonstration by Berkhold in 1849 that autotransplanted testes led to the acquisition of secondary characteristics in castrated cocks marked the beginning of experimental endocrinology. Endocrine autografts used successfully in modern surgical practice include:
A. Adrenal medulla to the brain.
B. Thyroid to the forearm.
C. Parathyroid to the forearm.
D. Testicle to the scrotum.
E. Pancreatic islets to the liver.
50. Several types of gastrointestinal autografts have been used to replace the esophagus after extirpation of carcinomas. Successful reconstructions have been achieved most frequently with:
D. Ascending colon.
E. Descending colon.
51. Which of the following statement(s) is/are true concerning the options for managing the exocrine secretions following pancreatic transplantation?
a. Ductal ligation is associated with no adverse effects to pancreatic parenchyma
b. Drainage of the pancreatic ductal system into the bladder is useful in the early diagnosis of rejection
c. All pancreatic grafts should be placed in a retroperitoneal position
d. Complications following enteric drainage of the pancreas (without the duodenum) are primarily associated with anastomatic leakage
Answer: b, d
52. The term “tolerance” refers to responses observed which include long-term graft acceptance without the need for chronic immunosuppression. There are a variety of specific ways in which T and B lymphocytes can be tolerant or nonresponsive to antigen. Which of the following is/are mechanisms of tolerance?
a. Clonal abortion
b. Clonal deletion
c. Clonal anergy
Answer: a, b, c, d
53. Which of the following statement (s) is/are true concerning currently approved immunosuppressant agents?
a. Azathioprine (Imuran) is useful in the treatment of acute ongoing rejection
b. Methylprednisolone is particularly useful in immunosuppression as it has lesser toxicity than Prednisone
c. Cyclosporine blocks transcription of several early T-cell activation genes
d. FK-506 is both more potent and less toxic than cyclosporine
e. The monoclonal antibody OKT3 interferes with T-cell antigen recognition function
Answer: c, e
54. Which of the following patients would be a candidate for a liver transplant?
a. A 48-year-old man with end-stage liver disease secondary to non-A, non-B hepatitis
b. A 35-year-old man with both primary sclerosing cholangitis and ulcerative colitis and end-stage liver disease
c. A 22-year-old woman with fulminant hepatic failure secondary to acetaminophen overdose
d. A 4-year-old child with congenital biliary atresia having failed a previous Kasai procedure
e. A 48-year-old patient with alcoholic cirrhosis and a 2.5 cm central unresectable hepatoma
Answer: a, b, c, d, e
55. Which of the following statement(s) is/are true concerning changes in physiology following lung transplant?
a. In patients with pulmonary hypertension, changes in right ventricular function and pulmonary artery pressure takes weeks to months to resolve
b. In single lung transplantation, changes in pulmonary function are seen almost immediately following transplantation
c. Patients with double lung transplants have both better pulmonary function studies as well as better exercise capabilities
d. After single-lung transplant, ventilation perfusion mismatch persists and carbon dioxide retention is seen
56. Current clinical protocols determine a limited number of variables and parameters for matching and allocation of donor organs to potential recipients. Which of the following statement(s) is/are true concerning aspects of immunity important for clinical transplantation?
a. HLA matching is important for kidney, pancreas, and liver transplantation
b. A cross match assay determines if there are preformed antibodies in the recipient’s serum which will react with antigens on the cell surface of the potential donor’s lymphocytes
c. A patient with a history of multiple transfusions or previous transplant will have a high panel reactive antibody (PRA)
d. A normal heterozygous individual with a complete donor-recipient match will have a four-antigen match
Answer: b, c
57. T-lymphocytes are divided into two main sub-classes: CD4+ and CD8+. Which of the following statement(s) is/are true concerning these classes of T-cells?
a. CD4+ T-cells are restricted to recognizing antigens of the class II major histocompatibility complex (MHC)
b. CD8+ T-cells perform primarily cytotoxic functions
c. CD4+ 8+ double positive cells are well-differentiated mature cells
d. CD4+ T-cells also perform suppressor functions
Answer: a, b, d
58. Correct statement(s) concerning postoperative complications after hepatic transplantation include:
a. Primary nonfunction occurs in 5 to 10% of transplanted livers in the immediate postoperative period
b. A biliary leak, although a common complication, is usually of minimal clinical importance
c. Portal vein thrombosis occurs much more commonly than hepatic artery thrombosis
d. If postoperative bleeding is encountered, immediate return to the operating room is indicated
59. Which of the following statement(s) is/are true concerning renal transplantation?
a. Living-related donor transplants typically can be expected to have one-year graft survival rates of over 90%
b. Preconditioning of the recipient with the use of donor-specific blood transfusions from their living donor improves graft survival and therefore should be used routinely
c. Pre-transplant blood transfusions result in improved graft survival following cadaveric renal transplant in the cyclosporine era
d. Age of the recipient over 50 years is generally associated with a poorer outcome due to graft rejection
60. Which of the following statement(s) is/are true concerning clinical syndromes of rejection?
a. Hyperacute rejection occurs with kidney, heart, liver and lung transplants
b. The histologic characteristics of acute rejection include lymphocyte infiltration accompanied by plasma cells, eosinophils, or neutrophils
c. Vascular atherosclerosis and obliteration are characteristic of chronic rejection
d. Transplantation across major ABO incompatibility will result in hyperacute rejection of a renal or cardiac transplant
Answer: b, d
61. Which of the following statement(s) is/are true concerning techniques for multiple organ procurement and preservation?
a. The liver and pancreas are generally removed en bloc and separated as a bench procedure
b. Renal allograft function is improved by the use of machine perfusion
c. UW (University of Wisconsin) cold storage solution is the method of choice of most programs for hepatic and pancreatic transplantation
d. Cardiac allografts have the shortest limit of cold ischemia
Answer: a, c, d
62. Which of the following statement(s) is/are true concerning the outcome of renal transplantation?
a. Two-thirds of all graft losses alone (without death) occur from one to six months after transplantation
b. The most common cause for graft loss after one year following transplantation is patient death
c. Most patient deaths following transplantation are related to immunosuppression
d. An acute rejection episode in a renal allograft recipient is the most important clinical event, determining both short-term and long-term graft survival
e. The period between the six months and one year following transplantation is the most critical time period following renal transplant
Answer: a, b, d
63. Which of the following characteristics or conditions will exclude a patient as a suitable cadaveric organ donor?
a. Active systemic bacterial infection
b. Primary CNS malignancy
c. Age over 65
d. History of prior cholecystectomy for a possible hepatic donor
64. Which of the following statement(s) is/are true concerning associated renal and pancreatic transplantation?
a. The most important advantage is the use of renal function as an early indicator of pancreatic graft rejection
b. After renal transplant, there is no additional risk associated with immunosuppression
c. A major disadvantage of simultaneous renal/pancreatic transplant is the potential adverse effect on renal allograft as the result of a pancreatic complication
d. A diabetic with a renal transplant continues to be at risk for diabetic nephropathy
Answer: a, b, c, d
65. There are numerous toxicities and adverse effects associated with immunosuppression. Which of the following statement(s) is/are true concerning complications of immunosuppression?
a. Transplant recipients are susceptible primarily to infections with unusual organisms (fungus, virus, atypical bacteria)
b. Immunosuppressive agents may blunt the inflammatory response to infection leading to a late presentation of an infectious process
c. The development of malignancy appears primarily due to direct mitogenic effects of the agent
d. Lymphomas are the most common malignant tumors developing in the transplant patient
e. Graft-vs-host disease is a progressive condition and extremely difficult to treat
66. Which of the following statement(s) is/are true concerning the results of lung transplantation?
a. One year survival following single lung transplant is significantly better than following bilateral transplant
b. The worst survival is seen in patients with pulmonary hypertension
c. Patients with cystic fibrosis have a markedly poorer result than do patients with emphysema
d. Infection is a common cause of mortality in both the early and late post-transplant period
Answer: b, d
67. Categories of patients in which pancreatic transplantation is applicable includes:
a. Diabetics with a functioning renal transplant
b. Diabetic patients with end-stage renal disease requiring renal transplantation
c. Nonuremic diabetics with other complications of their disease
d. Well-controlled adult onset diabetics
Answer: a, b, c
68. Which of the following statement(s) is/are true concerning the results of cardiac transplantation?
a. Overall one-year survival is approximately 80%
b. Survival following transplant in the pediatric age group is significantly worse than in adults
c. There is no difference in survival when cardiac transplantation is performed in a heterotopic position versus an orthotopic position
d. The survival rate for retransplantation is approximately 50%
Answer: a, d