CCTN Certified Clinical Transplant Nurse 2 — Questions and Answers
Question 1: A kidney transplant recipient on tacrolimus develops a serum creatinine rise from 1.2 to 2.8 mg/dL on post-op day 5. The most appropriate next step is:
- Increase tacrolimus dose immediately
- Obtain a renal biopsy to differentiate rejection from tacrolimus nephrotoxicity (Correct answer)
- Start high-dose IV methylprednisolone empirically
- Discontinue tacrolimus and switch to cyclosporine
Correct answer: Obtain a renal biopsy to differentiate rejection from tacrolimus nephrotoxicity
A renal biopsy is the gold standard to distinguish acute rejection from calcineurin inhibitor nephrotoxicity, as treatment differs significantly.
Question 2: Which of the following cytomegalovirus (CMV) serostatus combinations carries the HIGHEST risk for CMV disease post-transplant?
- Donor negative / Recipient positive (D-/R+)
- Donor positive / Recipient negative (D+/R-) (Correct answer)
- Donor positive / Recipient positive (D+/R+)
- Donor negative / Recipient negative (D-/R-)
Correct answer: Donor positive / Recipient negative (D+/R-)
A CMV-seropositive donor transplanted into a seronegative recipient (D+/R-) poses the highest risk because the recipient has no pre-existing immunity.
Question 3: A liver transplant patient on mycophenolate mofetil (MMF) reports persistent diarrhea. The nurse should first:
- Stop MMF immediately
- Switch to enteric-coated mycophenolate sodium to reduce GI side effects (Correct answer)
- Add loperamide and continue MMF unchanged
- Reduce tacrolimus trough level
Correct answer: Switch to enteric-coated mycophenolate sodium to reduce GI side effects
Enteric-coated mycophenolate sodium delivers the drug to the small intestine, reducing upper GI side effects including diarrhea.
Question 4: During a living donor kidney evaluation, the potential donor is found to have a glomerular filtration rate (GFR) of 72 mL/min/1.73 m². The transplant team should:
- Proceed with donation since GFR >60 mL/min is acceptable
- Decline the donor; GFR must be >80 mL/min for donation
- Evaluate further with a 24-hour urine collection and repeat measurement (Correct answer)
- Immediately approve donation as the GFR is within normal limits
Correct answer: Evaluate further with a 24-hour urine collection and repeat measurement
A borderline GFR requires further evaluation including 24-hour urine for creatinine clearance and protein to ensure safe residual function post-donation.
Question 5: Post-liver transplant, a patient develops fever, right upper quadrant pain, and elevated liver enzymes on day 10. Doppler ultrasound shows absent hepatic artery flow. This finding is MOST consistent with:
- Acute cellular rejection
- Hepatic artery thrombosis (Correct answer)
- Primary non-function
- Biliary anastomotic leak
Correct answer: Hepatic artery thrombosis
Hepatic artery thrombosis typically presents with fever, elevated enzymes, and absent arterial flow on Doppler in the early post-operative period.
Question 6: The immunosuppression protocol known as induction therapy in transplantation refers to:
- Long-term low-dose steroids used to prevent rejection
- Intensive immunosuppression given perioperatively to reduce early rejection risk (Correct answer)
- Withdrawal of immunosuppression to test for tolerance
- Prophylactic antibiotics given before surgery
Correct answer: Intensive immunosuppression given perioperatively to reduce early rejection risk
Induction therapy uses potent immunosuppressive agents perioperatively to reduce the immune response when the allograft is most vulnerable to rejection.
Question 7: A heart transplant patient is being evaluated six months post-transplant with an endomyocardial biopsy. The pathology report reads 'Grade 2R acute cellular rejection.' According to ISHLT grading, this indicates:
- No rejection; routine follow-up only
- Mild rejection not requiring treatment
- Moderate rejection requiring augmented immunosuppression (Correct answer)
- Severe rejection with hemodynamic compromise
Correct answer: Moderate rejection requiring augmented immunosuppression
Grade 2R (moderate) acute cellular rejection per ISHLT 2004 criteria typically warrants treatment with pulse steroids or augmented immunosuppression.
CCTN Certified Clinical Transplant Nurse 2
A kidney transplant recipient on tacrolimus develops a serum creatinine rise from 1.2 to 2.8 mg/dL on post-op day 5.
The most appropriate next step is: