CMSRN Transplant 2 — Questions and Answers
Question 1: A kidney transplant recipient on day 3 post-op develops fever, oliguria, and graft tenderness. Which complication is most likely?
- Hyperacute rejection
- Acute cellular rejection (Correct answer)
- Chronic rejection
- Calcineurin inhibitor toxicity
Correct answer: Acute cellular rejection
Acute cellular rejection typically presents days to weeks post-transplant with fever, oliguria, and graft tenderness, and is T-cell mediated.
Question 2: Which immunosuppressant combination is standard maintenance therapy for solid organ transplant recipients?
- Cyclosporine + azathioprine + prednisone
- Tacrolimus + mycophenolate mofetil + prednisone (Correct answer)
- Sirolimus + methotrexate + prednisone
- Basiliximab + tacrolimus + azathioprine
Correct answer: Tacrolimus + mycophenolate mofetil + prednisone
The standard triple immunosuppression regimen is tacrolimus, mycophenolate mofetil, and a corticosteroid.
Question 3: A liver transplant patient develops jaundice, elevated liver enzymes, and pruritus 6 months post-transplant. These findings are most consistent with:
- Acute cellular rejection
- Primary non-function
- Chronic rejection (ductopenic rejection) (Correct answer)
- Hepatic artery thrombosis
Correct answer: Chronic rejection (ductopenic rejection)
Chronic rejection, also called ductopenic rejection, presents months to years post-transplant with progressive cholestasis and loss of bile ducts.
Question 4: The nurse is caring for a post-renal transplant patient whose tacrolimus trough level is 18 ng/mL (therapeutic range 8–12 ng/mL). Which assessment finding is most concerning?
- Blood glucose of 140 mg/dL
- Serum creatinine rise from 1.0 to 1.8 mg/dL (Correct answer)
- Mild hand tremor
- Blood pressure of 138/86 mmHg
Correct answer: Serum creatinine rise from 1.0 to 1.8 mg/dL
Supratherapeutic tacrolimus causes nephrotoxicity; a rising creatinine indicates calcineurin inhibitor-induced renal injury requiring dose reduction.
Question 5: Which post-transplant infection is associated with a CD4+ count below 200 cells/µL and reactivation of a latent opportunistic organism?
- CMV viremia
- Pneumocystis jirovecii pneumonia (PJP) (Correct answer)
- BK virus nephropathy
- Post-transplant lymphoproliferative disorder
Correct answer: Pneumocystis jirovecii pneumonia (PJP)
PJP occurs when profound immunosuppression lowers CD4+ counts, reactivating latent Pneumocystis jirovecii; TMP-SMX prophylaxis is standard.
Question 6: A heart transplant recipient presents with dyspnea, fatigue, and an endomyocardial biopsy showing Grade 2R rejection. The most appropriate treatment is:
- Observation and repeat biopsy in 2 weeks
- High-dose IV methylprednisolone pulse therapy (Correct answer)
- Plasmapheresis and IVIG
- Immediate retransplantation listing
Correct answer: High-dose IV methylprednisolone pulse therapy
ISHLT Grade 2R moderate acute cellular rejection is treated with high-dose IV corticosteroid pulse therapy.
Question 7: Which laboratory finding is most indicative of primary graft non-function immediately after liver transplantation?
- ALT 1,200 U/L with improving trend
- Serum creatinine of 2.0 mg/dL
- INR > 3.0 unresponsive to vitamin K with persistent encephalopathy (Correct answer)
- Total bilirubin of 4 mg/dL on day 2
Correct answer: INR > 3.0 unresponsive to vitamin K with persistent encephalopathy
Primary non-function is characterized by failure to produce bile, coagulopathy unresponsive to treatment, encephalopathy, and rapidly rising bilirubin requiring urgent retransplant.
CMSRN Transplant 2
A kidney transplant recipient on day 3 post-op develops fever, oliguria, and graft tenderness.
Which complication is most likely?