CCTC Long-Term Recipient Management 4 — Questions and Answers
Question 1: A post-transplant patient is prescribed fluconazole for a fungal infection. The transplant coordinator should anticipate the need to:
- Increase the tacrolimus dose due to decreased absorption
- Decrease the tacrolimus dose due to CYP3A4 inhibition (Correct answer)
- Switch the patient to cyclosporine
- Stop mycophenolate during antifungal therapy
Correct answer: Decrease the tacrolimus dose due to CYP3A4 inhibition
Fluconazole is a potent CYP3A4 inhibitor that significantly increases tacrolimus levels; the dose must be reduced and levels monitored closely.
Question 2: Post-transplant osteoporosis is MOST commonly caused by long-term use of which immunosuppressive drug class?
- Calcineurin inhibitors
- Corticosteroids (Correct answer)
- Mycophenolate derivatives
- mTOR inhibitors
Correct answer: Corticosteroids
Corticosteroids are the primary driver of post-transplant bone loss through inhibition of osteoblast function and increased calcium excretion.
Question 3: A liver transplant recipient develops new-onset tremors and confusion 5 years post-transplant. Tacrolimus level is 18 ng/mL. The MOST likely cause is:
- Acute cellular rejection of the liver
- Tacrolimus neurotoxicity (Correct answer)
- CMV encephalitis
- Post-transplant lymphoma
Correct answer: Tacrolimus neurotoxicity
Supratherapeutic tacrolimus levels (>15 ng/mL) are associated with neurotoxicity including tremors, confusion, and posterior reversible encephalopathy syndrome (PRES).
Question 4: Which intervention is recommended to reduce cardiovascular mortality in long-term kidney transplant recipients?
- Routine cardiac catheterization every 2 years
- Statin therapy for dyslipidemia management (Correct answer)
- Prophylactic aspirin for all recipients regardless of risk
- Routine coronary artery bypass grafting at year 5
Correct answer: Statin therapy for dyslipidemia management
Cardiovascular disease is the leading cause of death in kidney transplant recipients; statin therapy reduces dyslipidemia and cardiovascular events in this population.
Question 5: A transplant recipient asks about dietary restrictions at their 3-year follow-up visit. Which food interaction remains a lifelong concern with calcineurin inhibitors?
- Dairy products reducing absorption
- Grapefruit juice increasing drug levels via CYP3A4 inhibition (Correct answer)
- High-protein diet causing nephrotoxicity
- Green tea reducing immunosuppression effectiveness
Correct answer: Grapefruit juice increasing drug levels via CYP3A4 inhibition
Grapefruit and grapefruit juice inhibit intestinal CYP3A4, significantly increasing tacrolimus and cyclosporine blood levels.
Question 6: When assessing medication adherence in a long-term transplant recipient, the MOST reliable indicator of non-adherence is:
- Patient self-report at each visit
- Intra-patient variability in tacrolimus trough levels (Correct answer)
- Periodic urine drug screening
- Monthly pill counts by the coordinator
Correct answer: Intra-patient variability in tacrolimus trough levels
High intra-patient variability (IPV) in tacrolimus troughs is the most objective marker of inconsistent medication adherence and is associated with worse graft outcomes.
Question 7: A 6-year post-kidney-transplant recipient is found to have de novo donor-specific antibodies (dnDSA) on routine screening. The coordinator should understand these are associated with:
- Improved long-term graft survival
- Increased risk of antibody-mediated rejection and graft loss (Correct answer)
- No clinical significance if creatinine is stable
- A protective immune adaptation to the allograft
Correct answer: Increased risk of antibody-mediated rejection and graft loss
De novo DSA are associated with chronic antibody-mediated rejection, accelerated graft dysfunction, and decreased long-term survival even when initially asymptomatic.
CCTC Long-Term Recipient Management 4
A post-transplant patient is prescribed fluconazole for a fungal infection.
The transplant coordinator should anticipate the need to: