47

Renal Transplantation

Hans Albin Gritsch; Jeremy Matthew Blumberg

Questions

1.Which of the following renal diseases has a high probability of recurrence in patients with a kidney transplant, resulting in failure of the kidney graft?

a.Chronic glomerulonephritis

b.Focal segmental glomerulosclerosis

c.IgA nephropathy

d.Alport syndrome

e.Autosomal dominant polycystic kidney disease

2.Lymphoproliferative disorders are most commonly associated with which of the following viruses?

a.Herpes simplex virus type 1

b.Varicella-zoster virus

c.Epstein-Barr virus (EBV)

d.Cytomegalovirus (CMV)

e.Cocksackie virus

3.Pretransplant nephrectomy is indicated for:

a.hypertension controlled with medication.

b.prior renal infection.

c.symptomatic renal stones.

d.200 mg/dL proteinuria.

e.most polycystic kidneys.

4.The best renal imaging protocol for a living renal donor to define renal anatomy and renal vasculature and to rule out renal stones is:

a.kidney, ureter, bladder (KUB) radiography and selective renal arteriography.

b.magnetic resonance nephrotomography and angiography.

c.helical computed tomography (CT) without and with intravenous iodinated contrast.

d.helical CT without and with intravenous iron contrast.

e.renal ultrasonography and selective renal arteriography.

5.After living donor nephrectomy, the renal donor is expected to have what level of total renal function?

a.50%

b.60%

c.75%

d.90%

e.95%

6.Kidney transplant survival rates are poorest for which of the following donor categories?

a.Sibling

b.Parent

c.Spouse

d.Standard criteria deceased

e.Expanded criteria deceased

7.Which of the following is required for the cellular sodium-potassium pump to maintain a high intracellular concentration of potassium and a low intracellular concentration of sodium?

a.ADP

b.ATP

c.CMP

d.CTP

e.Nitric oxide

8.The best solution for preservation of all abdominal organs is:

a.EuroCollins.

b.Collins 2.

c.Sach solution.

d.University of Wisconsin (UW) solution.

e.Histidine-tryptophan-ketoglutarate (HTK).

9.A cadaver kidney transplant recipient receives points on the national waiting list for all of the following EXCEPT:

a.time on the waiting list.

b.age younger than 18 years.

c.panel reactive antibody (PRA) level greater than 80%.

d.histocompatibility.

e.full-time employment.

.The standard method of urinary tract reconstruction during renal transplantation is:

a.ureteropyelostomy.

b.ureteroureterostomy.

c.ureteroneocystostomy.

d.vesicopyelostomy.

e.cutaneous ureterostomy.

.A woman wishes to donate a kidney to her husband who has end-stage renal disease (ESRD). She is ABO blood type A, and he is ABO blood type O. Each of the following is a possible solution to this problem EXCEPT:

a.plasmapheresis.

b.immunoadsorption.

c.immunoglobulin administration.

d.anti CD-37 antibody administration.

e.paired kidney exchange.

.The risk of a hyperacute rejection after kidney transplantation is high when which of the following is positive?

a.B-cell flow cross match

b.T-cell flow cross match

c.B-cell complement-dependent cytotoxicity cross match

d.T-cell complement-dependent cytotoxicity cross match

e.DR-cell cross match

.Which of the following immunosuppressants inhibits cell cycle progression?

a.Azathioprine

b.Mycophenolate mofetil

c.Cyclosporine

d.Tacrolimus

e.Sirolimus

.Which of the following paired immunosuppressants have similar mechanisms of action and toxicity?

a.Azathioprine and cyclosporine

b.Azathioprine and tacrolimus

c.Basiliximab and mycophenolate mofetil

d.Tacrolimus and cyclosporine

e.OKT3 and mycophenolate mofetil

.Which of the following two drugs have been used to reduce calcineurin inhibitor dosing and cost while maintaining blood levels and immunosuppressive effect?

a.Diltiazem and ketoconazole

b.Prednisone and azathioprine

c.Basiliximab and daclizumab

d.Equine antilymphocyte globulin and azathioprine

e.Mycophenolate mofetil and azathioprine

.Prophylaxis against Pneumocystis infection is best achieved with:

a.trimethoprim-sulfamethoxazole.

b.erythromycin.

c.ciprofloxacin.

d.cephalexin.

e.minocycline.

.Prophylaxis against cytomegalovirus infection is best done with:

a.trimethoprim-sulfamethoxazole.

b.erythromycin.

c.ganciclovir.

d.basiliximab.

e.minocycline.

.Five years after successful renal transplantation, a 55-year-old man is referred to you because of total gross hematuria. Each of the following is an important part of the workup EXCEPT:

a.urine cytology.

b.urine PCA3 determination.

c.images of the native kidneys.

d.images of the kidney transplant.

e.cystourethroscopy.

.Which of the following interferes with the tubular secretion of creatinine and can cause an increase in serum creatinine levels?

a.Azathioprine

b.Trimethoprim

c.Mycophenolate mofetil

d.Tacrolimus

e.Basiliximab

.Oral fluconazole is prescribed to treat cystitis caused by yeast. Which of the following medications will need to have the dose reduced?

a.Muromonab-CD3

b.Prednisone

c.Tacrolimus

d.Azathioprine

e.Mycophenolate mofetil

.Hemorrhagic cystitis in an immunosuppressed patient has been most commonly associated with which of the following viruses?

a.Cytomegalovirus

b.Adenovirus

c.Herpes simplex virus type 1

d.Herpes simplex virus type 2

e.Polyoma virus

.The most common cancer after kidney transplantation is:

a.skin.

b.cervix.

c.Kaposi sarcoma.

d.thyroid.

e.breast.

.Hyperlipidemia is most often associated with which of the following threedrug combinations?

a.Prednisone, cyclosporine, sirolimus

b.Equine antithymocyte globulin, tacrolimus, mycophenolate mofetil

c.Mycophenolate mofetil, tacrolimus, basiliximab

d.Cyclosporine, tacrolimus, mycophenolate mofetil

e.Basiliximab, mycophenolate mofetil, azathioprine

.A kidney transplant patient with chronic rejection presents with constipation. The contraindicated treatment is:

a.oral docusate calcium

b.oral psyllium

c.polyethylene glycol–electrolyte solution

d.phospho-soda enema

e.soap suds enema

.Patients with chronic renal insufficiency should be referred for kidney transplant evaluation when:

a.the disease is confirmed by kidney biopsy.

b.the estimated glomerular filtration rate is less than 20 mg/dL.

c.the estimated glomerular filtration rate is less than 8 mg/dL.

d.they are on dialysis.

e.they have identified a living kidney donor.

.The peritoneal dialysis solution containing the following compound that may lead to false point-of-care glucose readings is:

a.dextran.

b.icodextrin.

c.glucose.

d.sucrose.

e.d-xylose.

.A 52-year-old diabetic man with a solitary right kidney has a 7-cm mass noted on ultrasound in the lower pole. He is blood type O and has had multiple abdominal operations including previous partial nephrectomies with blood transfusions. His serum creatinine is 2.3 mg/dL and he is not aware of any potential kidney transplant donors. In preparation for partial nephrectomy he should have:

a.referral to a vascular surgeon for creation of a dialysis fistula prior to surgery.

b.consent for placement of a peritoneal dialysis catheter.

c.magnetic resonance angiogram with gadolinium contrast.

d.computed tomography with iodinated contrast.

e.referral to a transplant surgeon.

.A frequent symptom associated with hyperphosphatemia is:

a.seizures.

b.flank pain.

c.headache.

d.diarrhea.

e.conjunctival itching.

.The most common causes of death following kidney transplant in order are:

a.kidney failure, sepsis, and cancer.

b.cancer, sepsis, and heart disease.

c.heart disease, sepsis, and stroke.

d.sepsis, cancer, and heart disease.

e.heart disease, cancer, and stroke.

.Which of the following has been associated with a higher incidence of mortality in living donor nephrectomies?

a.Open donor nephrectomy

b.Ligation of the renal vein with an Endo-GIA stapling device

c.Ligation of the renal artery with a single Hem-o-Lok® clip

d.Insufflation with a Veress needle during laparoscopic donor nephrectomy

e.Retroperitoneoscopic donor nephrectomy

.A 54-year-old male with ESRD due to type 2 diabetes mellitus has been on hemodialysis for 2 years and is referred for transplant evaluation. Which of the following is an absolute contraindication to renal transplantation?

a.Gleason 3 + 3 prostate cancer treated by radical prostatectomy 1 year ago

b.Recent development of a gangrenous toe

c.Gleason 3 + 4 prostate cancer treated with external beam radiation 3 years ago; prostate-specific antigen (PSA) currently 0.2 ng/mL

d.A T1aN0Mx, Fuhrman grade 2 renal cell carcinoma treated by radical nephrectomy 1 year ago

e.History of right below-the-knee amputation 4 years ago, currently using prosthesis and able to walk 100 yards with no difficulty

.All of the following place a deceased donor into the Centers for Disease Control’s "high-risk" category EXCEPT a:

a.man who has had sex with another man during the previous month.

b.donor who has smoked crack cocaine within the last year.

c.history of intravenous heroin use 3 years ago.

d.man who was released from prison after a 15-year sentence 5 days before the pronouncement of brain death.

e.23-year-old woman who was currently working as a prostitute.

.Regarding allograft nephrectomy, which of the following statements is TRUE?

a.Allograft nephrectomy is indicated for all failed kidney transplants.

b.Allograft nephrectomy is a relatively simple procedure and can be performed without significant prior experience.

c.Levels of circulating anti-human leukocyte antigen (HLA) antibodies may be reduced by allograft nephrectomy if the transplant fails within the first year.

d.Post-transplant gross hematuria arising from the transplant is an absolute indication for allograft nephrectomy.

e.Allograft nephrectomy is mandatory if a patient is a candidate for a

second renal transplant.

.The test that is most sensitive for finding donor-specific antibodies (DSA) is: a. complement dependent lymphocytotoxicity assay.