CCTC Long-Term Recipient Management 3 — Questions and Answers
Question 1: A renal transplant recipient presents 18 months post-transplant with fever, fatigue, and a CD4 count of 120 cells/µL. CMV viremia is negative. Which opportunistic infection should be highest on the differential?
- Pneumocystis jirovecii pneumonia (PJP) (Correct answer)
- Cytomegalovirus colitis
- BK virus nephropathy
- Cryptococcal meningitis
Correct answer: Pneumocystis jirovecii pneumonia (PJP)
PJP prophylaxis is often discontinued at 6-12 months, leaving patients vulnerable; low CD4 count and fever in an immunosuppressed host strongly suggests PJP.
Question 2: BK virus nephropathy in kidney transplant recipients is best managed initially by:
- Adding antiviral therapy with ganciclovir
- Reducing overall immunosuppression (Correct answer)
- Pulse dose corticosteroids
- Switching from tacrolimus to cyclosporine
Correct answer: Reducing overall immunosuppression
The primary treatment for BK nephropathy is reduction of immunosuppression to allow immune reconstitution and viral clearance; no antiviral has proven efficacy.
Question 3: A transplant coordinator is reviewing a 4-year post-liver-transplant patient's labs and notes eGFR of 35 mL/min/1.73m². Which immunosuppressant is most implicated in this long-term complication?
- Mycophenolate mofetil
- Prednisone
- Calcineurin inhibitors (tacrolimus/cyclosporine) (Correct answer)
- Azathioprine
Correct answer: Calcineurin inhibitors (tacrolimus/cyclosporine)
Chronic calcineurin inhibitor (CNI) nephrotoxicity is a leading cause of chronic kidney disease in non-renal solid organ transplant recipients.
Question 4: Which test is the recommended screening for post-transplant lymphoproliferative disorder (PTLD) in high-risk patients?
- CT scan every 6 months
- EBV viral load monitoring (Correct answer)
- Bone marrow biopsy annually
- Peripheral blood flow cytometry quarterly
Correct answer: EBV viral load monitoring
EBV-negative recipients who receive EBV-positive organs are at highest risk for PTLD; serial EBV PCR monitoring allows early detection and immunosuppression reduction.
Question 5: A kidney transplant recipient at 2 years post-transplant has proteinuria of 1.8 g/day on urinalysis. The BEST next step is:
- Start mycophenolate and watch for 6 months
- Perform a kidney transplant biopsy (Correct answer)
- Begin dialysis preparation
- Increase tacrolimus dose
Correct answer: Perform a kidney transplant biopsy
New-onset significant proteinuria requires allograft biopsy to distinguish recurrent glomerulonephritis, chronic rejection, and de novo glomerular disease.
Question 6: Which annual screening is MOST important for female transplant recipients on long-term immunosuppression?
- Annual echocardiogram
- Annual Pap smear and HPV testing (Correct answer)
- Annual bone density scan only
- Annual PET scan
Correct answer: Annual Pap smear and HPV testing
Immunosuppression increases the risk of HPV-related cervical dysplasia and cancer; annual cervical screening is recommended for female transplant recipients.
Question 7: A stable lung transplant recipient at 3 years post-transplant shows a progressive decline in FEV1 to 65% of baseline without infection. This pattern is consistent with:
- Primary graft dysfunction
- Acute rejection episode
- Bronchiolitis obliterans syndrome (BOS) (Correct answer)
- Pleural effusion
Correct answer: Bronchiolitis obliterans syndrome (BOS)
Bronchiolitis obliterans syndrome is defined by persistent decline in FEV1 to <80% of best post-transplant value and represents the most common form of chronic lung allograft dysfunction.
CCTC Long-Term Recipient Management 3
A renal transplant recipient presents 18 months post-transplant with fever, fatigue, and a CD4 count of 120 cells/µL.
CMV viremia is negative.
Which opportunistic infection should be highest on the differential?