CMSRN Transplant 5 — Questions and Answers
Question 1: A pancreas transplant patient develops hyperglycemia requiring insulin on post-op day 5 after previously achieving normoglycemia. Which complication should be investigated first?
- Pancreatic fistula
- Acute rejection of the pancreas graft (Correct answer)
- Surgical site infection
- Medication-induced hyperglycemia from steroids
Correct answer: Acute rejection of the pancreas graft
Return of hyperglycemia after initial normoglycemia is a sign of pancreatic graft rejection; rising amylase/lipase and imaging confirm the diagnosis.
Question 2: A patient awaiting a liver transplant develops acute-on-chronic liver failure with hepatic encephalopathy. The nurse recognizes this patient will receive transplant priority because:
- A higher MELD score increases waiting-list ranking
- Status 1A listing is assigned for fulminant hepatic failure (Correct answer)
- Geographic proximity to a donor overrides severity
- Child-Pugh class C automatically triggers organ offer
Correct answer: Status 1A listing is assigned for fulminant hepatic failure
UNOS Status 1A designates patients with fulminant hepatic failure or acute decompensation with life expectancy < 7 days, giving them highest priority.
Question 3: Which cytomegalovirus (CMV) risk category has the highest risk for post-transplant CMV disease?
- Donor negative / Recipient positive (D-/R+)
- Donor positive / Recipient positive (D+/R+)
- Donor negative / Recipient negative (D-/R-)
- Donor positive / Recipient negative (D+/R-) (Correct answer)
Correct answer: Donor positive / Recipient negative (D+/R-)
D+/R− (donor CMV-seropositive, recipient CMV-seronegative) carries the highest risk because the recipient has no pre-existing immunity against the donor's CMV.
Question 4: When performing post-transplant patient education, the nurse emphasizes sun protection because transplant recipients are at highest risk for which skin cancer?
- Basal cell carcinoma
- Malignant melanoma
- Merkel cell carcinoma
- Squamous cell carcinoma (Correct answer)
Correct answer: Squamous cell carcinoma
Squamous cell carcinoma is the most common skin malignancy in transplant recipients and is far more aggressive than in the general population due to immunosuppression.
Question 5: A renal transplant patient's cyclosporine level is subtherapeutic. The patient reports starting rifampin for latent TB prophylaxis. This interaction occurs because rifampin:
- Displaces cyclosporine from plasma protein binding
- Inhibits CYP3A4, reducing cyclosporine metabolism
- Induces CYP3A4, accelerating cyclosporine metabolism (Correct answer)
- Increases renal excretion of cyclosporine
Correct answer: Induces CYP3A4, accelerating cyclosporine metabolism
Rifampin is a potent CYP3A4 inducer that markedly increases cyclosporine metabolism, leading to subtherapeutic levels and risk of rejection.
Question 6: A nurse caring for a patient 48 hours after orthotopic heart transplant notes the patient lacks the normal heart rate response to the Valsalva maneuver. The best explanation is:
- Beta-blocker administration is blunting heart rate response
- The transplanted heart is denervated and lacks autonomic reflex responses (Correct answer)
- Sinus node dysfunction from ischemia-reperfusion injury
- Elevated preload preventing normal heart rate changes
Correct answer: The transplanted heart is denervated and lacks autonomic reflex responses
The transplanted heart is surgically denervated; it does not respond to vagal or sympathetic maneuvers and relies on intrinsic automaticity and circulating catecholamines.
Question 7: A patient post-bilateral lung transplant develops progressive obstructive airflow limitation on spirometry at 14 months, with an FEV1 decline > 20% from baseline. This pattern is consistent with:
- Primary graft dysfunction
- Acute cellular rejection
- Bronchiolitis obliterans syndrome (chronic lung allograft dysfunction) (Correct answer)
- Pleural fibrosis
Correct answer: Bronchiolitis obliterans syndrome (chronic lung allograft dysfunction)
Bronchiolitis obliterans syndrome is the hallmark of chronic lung allograft dysfunction, characterized by progressive, irreversible obstructive spirometry changes after the first post-transplant year.
CMSRN Transplant 5
A pancreas transplant patient develops hyperglycemia requiring insulin on post-op day 5 after previously achieving normoglycemia.
Which complication should be investigated first?