Certified Clinical Transplant Coordinator (CCTC) — Questions and Answers

Question 1: During a pre-transplant education session for a patient being evaluated for simultaneous pancreas-kidney (SPK) transplant, the patient states: 'My neighbor had a kidney transplant and said he only needs to take one pill a day now — will I have the same after SPK?' Which is the MOST accurate and therapeutically responsible educational response?

Advise the patient that once euglycemia is restored by the pancreas allograft, immunosuppression requirements decrease significantly because the immune system is less reactive in normoglycemic states
Explain that SPK recipients generally require a more intensive immunosuppression regimen than kidney-alone recipients due to the higher immunogenicity of the pancreatic allograft, plus ongoing monitoring for both organs (Correct answer)
Confirm that SPK recipients are typically maintained on a simplified single-drug regimen similar to kidney-alone recipients, since restored pancreatic function reduces the need for metabolic medications
Inform the patient that medication burden is identical across all solid organ transplant types and that the neighbor's regimen reflects standard post-transplant care

Correct answer: Explain that SPK recipients generally require a more intensive immunosuppression regimen than kidney-alone recipients due to the higher immunogenicity of the pancreatic allograft, plus ongoing monitoring for both organs

SPK transplantation involves two allografts, and the pancreatic allograft is more immunogenic than the kidney alone, requiring more intensive and sustained immunosuppression. SPK recipients typically receive triple immunosuppression (calcineurin inhibitor + antimetabolite + corticosteroid) and require monitoring for both renal and pancreatic function (amylase, lipase, glucose, C-peptide, creatinine). The neighbor's single-pill regimen may reflect a highly stable, long-term kidney recipient — not the standard, and certainly not applicable to SPK. Normoglycemia does not reduce immune reactivity. Setting accurate expectations about medication complexity is a critical pre-transplant education objective.

Question 2: During allocation, a transplant coordinator learns that a listed recipient's transplant surgeon is also a part-owner of the private surgical center where the transplant will be performed, and that center receives a per-case facility fee. This situation PRIMARILY raises which ethical concern under ASTS and UNOS standards?

A HIPAA violation because the financial arrangement constitutes unauthorized use of PHI
Breach of recipient confidentiality if the financial relationship is disclosed to the patient
Conflict of interest requiring disclosure and potential recusal from allocation decisions involving that center (Correct answer)
Fraudulent billing, which must be reported immediately to the Office of Inspector General

Correct answer: Conflict of interest requiring disclosure and potential recusal from allocation decisions involving that center

The primary ethical concern is a conflict of interest: the surgeon stands to gain financially from performing the transplant at a facility in which they have an ownership stake, which could — consciously or not — influence clinical decision-making or allocation advocacy. ASTS and UNOS standards require disclosure of such relationships and may require recusal from decisions where the conflict is material. While billing irregularities may warrant scrutiny, the threshold question is the conflict of interest disclosure obligation, not immediate OIG reporting.

Question 3: A liver transplant recipient is diagnosed with BK virus-associated nephropathy (BKVAN) in their native kidneys 14 months post-transplant. Their current immunosuppression is tacrolimus, mycophenolate mofetil (MMF), and prednisone. Serum BK PCR is 85,000 copies/mL. Which is the MOST appropriate initial management strategy?

Initiate IV cidofovir at standard dosing with probenecid
Switch tacrolimus to cyclosporine and maintain MMF dose unchanged
Add leflunomide to the current regimen without changing other agents
Reduce or discontinue MMF and reduce tacrolimus trough target (Correct answer)

Correct answer: Reduce or discontinue MMF and reduce tacrolimus trough target

The cornerstone of BKVAN management is immunosuppression reduction, not antiviral therapy, since no antiviral has proven efficacy in controlled trials. The standard approach is to reduce MMF (the agent with greatest impact on BK replication) and lower tacrolimus trough targets. Cidofovir has nephrotoxicity that limits its use and lacks robust evidence for BKVAN. Switching to cyclosporine without adjusting MMF does not adequately reduce the immunosuppressive burden in the right direction. Leflunomide has been used off-label but adding it without reducing existing immunosuppression would increase rather than reduce the net state of immunosuppression initially.

Question 4: A living donor candidate discloses she is in a financial relationship where the recipient's family is paying her rent. What is the appropriate next step?

Immediately exclude the candidate for financial incentive
Document the finding and continue without further action
Proceed with evaluation as financial arrangements are legal
Report the arrangement to the ethics committee and conduct further assessment for coercion (Correct answer)

Correct answer: Report the arrangement to the ethics committee and conduct further assessment for coercion

Financial arrangements between donor and recipient raise coercion concerns and must be reviewed by the ethics committee before proceeding.

Question 5: A transplant coordinator is managing a 58-year-old kidney transplant recipient 14 years post-transplant who develops squamous cell carcinoma (SCC) of the skin — the third cutaneous SCC in 24 months, with the most recent lesion showing perineural invasion on pathology. He remains on tacrolimus 3 mg/day and mycophenolate sodium 720 mg BID. His graft function is stable (eGFR 52). Which evidence-based immunosuppression strategy should the coordinator escalate to the transplant physician?

Reduction of mycophenolate dose by 50% while maintaining current tacrolimus levels
Addition of systemic retinoids to current regimen without altering immunosuppression
Conversion from tacrolimus to an mTOR inhibitor (sirolimus or everolimus) to leverage its antineoplastic properties (Correct answer)
Conversion to belatacept-based regimen to eliminate CNI-related skin cancer risk

Correct answer: Conversion from tacrolimus to an mTOR inhibitor (sirolimus or everolimus) to leverage its antineoplastic properties

In solid organ transplant recipients with aggressive or recurrent cutaneous squamous cell carcinoma, conversion from CNI to mTOR inhibitor therapy is supported by multiple randomized trials (including TUMORAPA) showing significant reduction in new skin malignancies. mTOR inhibitors inhibit the PI3K/AKT/mTOR pathway involved in tumor angiogenesis and proliferation. Perineural invasion indicates a high-risk SCC requiring aggressive management. Mycophenolate dose reduction alone without targeting the CNI is insufficient. Retinoids can reduce new lesions as adjunct therapy but do not address immunosuppression intensity. Belatacept conversion has not been shown to reduce skin malignancy risk compared to mTOR inhibitors.

Question 6: A lung transplant patient develops increasing hypoxia with bilateral infiltrates on CXR within 72 hours of transplant. What is the most likely diagnosis?

Acute cellular rejection
Primary graft dysfunction (PGD) (Correct answer)
Ventilator-associated pneumonia
Pulmonary embolism

Correct answer: Primary graft dysfunction (PGD)

Primary graft dysfunction presents within 72 hours with hypoxia and bilateral infiltrates from ischemia-reperfusion injury to the donor lung.

Question 7: What is the primary role of an Organ Procurement Organization (OPO) in the transplantation process?

Providing lifelong post-transplant follow-up care
Performing transplant surgeries at recipient centers
Coordinating organ recovery, preservation, and allocation (Correct answer)
Managing recipient immunosuppression protocols

Correct answer: Coordinating organ recovery, preservation, and allocation

OPOs identify potential donors, coordinate consent, manage organ recovery and preservation, and facilitate allocation through UNOS/OPTN.

Question 8: A transplant coordinator is educating a recipient who has developed New-Onset Diabetes After Transplantation (NODAT). Which of the following immunosuppressive agents is most strongly associated with the development of this complication?

Sirolimus
Azathioprine
Mycophenolate Mofetil
Tacrolimus (Correct answer)

Correct answer: Tacrolimus

Calcineurin inhibitors, particularly tacrolimus, and corticosteroids are the immunosuppressive agents most strongly linked to the development of NODAT. Tacrolimus is known to be toxic to pancreatic islet cells and can induce insulin resistance. While sirolimus can also contribute, the association is strongest with tacrolimus.

Question 9: A liver being preserved in University of Wisconsin (UW) solution shows signs of sinusoidal endothelial cell injury on back-table assessment. Which component of UW solution is specifically intended to prevent this cell type's swelling during cold ischemia?

Hydroxyethyl starch (HES) (Correct answer)
Glutathione
Adenosine
Lactobionate

Correct answer: Hydroxyethyl starch (HES)

Hydroxyethyl starch (HES) in UW solution acts as an oncotic agent to prevent interstitial edema and sinusoidal endothelial cell swelling, which are particularly vulnerable to cold-induced cell swelling. Lactobionate chelates iron to reduce free radical production and acts as an impermeant to limit intracellular edema. Glutathione is an antioxidant targeting reperfusion injury, and adenosine supports energy metabolism — neither specifically targets sinusoidal endothelial swelling.

Question 10: A potential living kidney donor discloses during the independent donor advocate meeting that she feels 'obligated' to donate because her brother paid off her student loans. She states she still 'wants' to donate but acknowledges she feels she 'owes' him. Which action is most ethically appropriate for the transplant coordinator?

Document the concern, provide additional counseling sessions, and allow the donor to proceed if she reaffirms consent after a mandatory 30-day waiting period
Halt the evaluation and refer the case to the transplant ethics committee, as the financial arrangement constitutes prohibited valuable consideration under the National Organ Transplant Act (Correct answer)
Notify the intended recipient's care team so they can counsel the recipient to voluntarily decline the offer, which removes the ethical burden from the program
Proceed with evaluation, as the donor verbally affirms her desire to donate and financial exchanges between family members are not prohibited by OPTN policy

Correct answer: Halt the evaluation and refer the case to the transplant ethics committee, as the financial arrangement constitutes prohibited valuable consideration under the National Organ Transplant Act

The National Organ Transplant Act (NOTA) prohibits the transfer of 'valuable consideration' for human organs. A prior financial benefit — even one framed as unrelated — that creates a sense of obligation in the donor undermines truly voluntary consent and may constitute coercion. The appropriate action is to halt evaluation and refer to the ethics committee. A 30-day waiting period alone does not resolve a structural coercion concern, and deflecting to the recipient's team violates the donor-recipient separation principle.

Question 11: A 45-year-old patient with alcoholic cirrhosis meets the 6-month sobriety requirement and is otherwise a strong transplant candidate. Toxicology screens have been consistently negative. However, during routine pre-transplant evaluation, a phosphatidylethanol (PEth) blood test returns at 220 ng/mL. The patient denies any alcohol use. What is the most accurate interpretation of this result?

PEth levels above 200 ng/mL are only clinically significant in patients with fatty liver disease and should not affect listing decisions in cirrhotic patients
A PEth level >200 ng/mL is strongly indicative of recent alcohol consumption within the past 3–4 weeks and warrants re-evaluation of sobriety claims despite negative urine toxicology (Correct answer)
The PEth result is likely a false positive due to cross-reactivity with lactulose, which is commonly used in cirrhosis management
A single elevated PEth should be disregarded if three consecutive urine ethanol screens are negative, as urine testing is the gold standard for alcohol detection

Correct answer: A PEth level >200 ng/mL is strongly indicative of recent alcohol consumption within the past 3–4 weeks and warrants re-evaluation of sobriety claims despite negative urine toxicology

Phosphatidylethanol (PEth) is a direct biomarker of alcohol consumption with a detection window of 3–4 weeks and high specificity for ethanol exposure. A level >200 ng/mL is considered strongly positive and indicates recent drinking. Urine ethanol screens have a detection window of only 12–24 hours, making them easy to circumvent. PEth is not cross-reactive with lactulose. This result warrants a formal sobriety reassessment regardless of negative urine tox screens.

Question 12: Which of the following best describes the ethical rationale for the 'dead donor rule' in transplantation?

Procurement of vital organs must not cause the death of the donor (Correct answer)
Organs harvested from living patients produce better outcomes than those from deceased donors
Donors must be legally declared dead by a cardiologist before procurement
The rule ensures that only brain-dead donors can contribute organs

Correct answer: Procurement of vital organs must not cause the death of the donor

The dead donor rule prohibits causing or hastening death to obtain organs, preserving donor dignity and public trust in the transplant system.

Question 13: What is the primary reason sirolimus (rapamycin) is often avoided in the early post-transplant period for kidney recipients?

It dramatically increases rejection rates compared to tacrolimus
It causes severe calcineurin inhibitor toxicity when combined
It directly nephrotoxic in the first month
It impairs wound healing and increases risk of lymphocele formation (Correct answer)

Correct answer: It impairs wound healing and increases risk of lymphocele formation

Sirolimus inhibits mTOR-dependent cell proliferation required for wound healing, increasing rates of wound complications and lymphocele formation in the early post-transplant period.

Question 14: During cardiovascular risk stratification for a 62-year-old diabetic patient awaiting liver transplant, a dobutamine stress echocardiogram reveals inducible wall motion abnormalities in the LAD territory. Coronary angiography subsequently demonstrates 75% stenosis of the proximal LAD. The cardiac surgeon recommends CABG. Which statement best reflects the transplant team's appropriate management of this finding?

The patient should undergo CABG, complete a structured cardiac rehabilitation program, and be re-evaluated for transplant candidacy after demonstrating functional recovery (Correct answer)
The patient can be listed immediately after CABG without further cardiac clearance since revascularization resolves the ischemic risk
The finding is an absolute contraindication to liver transplant and the patient should be permanently delisted
PCI with stenting is preferred over CABG in this scenario because it avoids the immunosuppression interaction risk associated with antiplatelet therapy post-CABG

Correct answer: The patient should undergo CABG, complete a structured cardiac rehabilitation program, and be re-evaluated for transplant candidacy after demonstrating functional recovery

Significant coronary artery disease is a correctable barrier in many cases, not an automatic absolute contraindication. The standard approach is revascularization followed by reassessment of functional cardiac status and candidacy. CABG does not eliminate the need for post-operative re-evaluation; the team must confirm adequate recovery and functional reserve before proceeding with transplant. Immediate listing post-CABG without re-evaluation is inappropriate.

Question 15: You are educating the adult daughter of a lung transplant recipient who will be the primary caregiver. The patient has limited English proficiency. Which approach BEST reflects evidence-based, patient- and family-centered education for this situation?

Use a qualified medical interpreter for the patient's education sessions while also providing translated written materials, and assess both patient and caregiver health literacy independently (Correct answer)
Provide all written materials in English and instruct the daughter to translate key concepts, since she is fluent and already present
Defer detailed education until after discharge when a Spanish-speaking home health nurse can conduct teaching in the patient's home
Use the daughter as the primary interpreter throughout all education sessions to build her caregiving competency alongside the patient

Correct answer: Use a qualified medical interpreter for the patient's education sessions while also providing translated written materials, and assess both patient and caregiver health literacy independently

Evidence-based practice and legal standards (Title VI of the Civil Rights Act) require qualified medical interpreters — not family members — for critical healthcare communication. Using family members as interpreters risks omission, distortion, and emotional burden, and they may filter information to protect the patient. Both the patient and caregiver must have their health literacy assessed independently, as the caregiver's understanding cannot substitute for the patient's autonomous comprehension. Deferring education post-discharge violates best practices for transplant readiness. Translated written materials reinforce verbal teaching.

Question 16: A pediatric transplant patient is transitioning to adult care. What is the primary psychosocial goal during this transition?

Reducing frequency of clinic follow-up appointments
Discontinuing family involvement in care decisions
Fostering self-management skills and independent health literacy in the young adult recipient (Correct answer)
Transferring all financial responsibilities to the young adult immediately

Correct answer: Fostering self-management skills and independent health literacy in the young adult recipient

Structured transition programs focus on developing self-advocacy, medication self-management, and health literacy to reduce non-adherence risk in young adult recipients.

Question 17: BK virus nephropathy is a serious complication primarily seen in which transplant recipient population?

Lung transplant recipients
Liver transplant recipients
Heart transplant recipients
Kidney transplant recipients (Correct answer)

Correct answer: Kidney transplant recipients

BK polyomavirus reactivates in renal tubular cells, causing BK nephropathy almost exclusively in kidney transplant recipients due to direct viral infection of the allograft.

Question 18: A liver transplant recipient who is stable on a sirolimus-based regimen is admitted for poor wound healing and a new-onset, significant leg edema. Laboratory results show 4+ proteinuria. These findings are most characteristic of the side-effect profile of which drug class?

Corticosteroids
mTOR inhibitors (Correct answer)
Antimetabolites
Calcineurin inhibitors (CNIs)

Correct answer: mTOR inhibitors

Sirolimus is an mTOR inhibitor. This class of drugs is known to cause impaired wound healing, peripheral edema, and significant proteinuria. While CNIs can be nephrotoxic, the combination of poor wound healing and heavy proteinuria is a classic presentation of mTOR inhibitor side effects. Corticosteroids can cause fluid retention but not typically this degree of proteinuria and wound impairment. Antimetabolites are not associated with these specific effects.

Question 19: Which parameter is used to calculate the Kidney Donor Risk Index (KDRI) to assess deceased donor kidney quality?

Multiple donor factors including age, height, weight, cause of death, and creatinine (Correct answer)
Cold ischemia time alone
Donor serum creatinine only
Recipient MELD score

Correct answer: Multiple donor factors including age, height, weight, cause of death, and creatinine

The KDRI is a composite score incorporating multiple donor characteristics to estimate the risk of graft failure relative to a reference donor.

Question 20: A lung transplant coordinator is reviewing immunosuppression for a bilateral lung transplant recipient who is 18 months post-transplant and has developed BOS (Bronchiolitis Obliterans Syndrome) Grade 2, confirmed by a sustained decline in FEV1 to 58% of post-transplant baseline on two measures 3 weeks apart. Current regimen is tacrolimus (trough 10 ng/mL), azathioprine, and prednisone 10 mg/day. Spirometric testing shows an obstructive pattern with no bronchodilator response. BAL shows no infection. Which intervention has the STRONGEST evidence for stabilizing BOS progression in this scenario?

Conversion from azathioprine to mycophenolate mofetil combined with initiation of azithromycin 250 mg three times weekly for its anti-inflammatory and immunomodulatory properties (Correct answer)
Escalation of tacrolimus trough target to 15–18 ng/mL and addition of pulse methylprednisolone 1g IV for 3 consecutive days
Initiation of pirfenidone to reduce fibroproliferative activity in the airways and slow FEV1 decline
Immediate re-transplant evaluation as BOS Grade 2 carries >80% mortality at 5 years and medical therapy is uniformly ineffective

Correct answer: Conversion from azathioprine to mycophenolate mofetil combined with initiation of azithromycin 250 mg three times weekly for its anti-inflammatory and immunomodulatory properties

Azithromycin has the strongest evidence base among medical interventions for BOS stabilization, with multiple studies showing FEV1 stabilization and, in some cases, partial improvement in a subset of patients (particularly those with neutrophilic reversible allograft dysfunction — NRAD phenotype). Its mechanism involves immunomodulatory and anti-inflammatory effects independent of antibiotic activity. Switching from azathioprine to mycophenolate mofetil is also commonly performed as part of BOS management, providing improved lymphocyte suppression. Escalating CNI beyond therapeutic range increases toxicity without established BOS benefit. Pulse steroids have limited evidence for established BOS. Re-transplantation is considered for refractory BOS but not as the immediate first step at Grade 2. Pirfenidone data in BOS/CLAD is preliminary and not standard of care.

Question 21: The Centers for Medicare & Medicaid Services (CMS) and OPTN policies mandate the use of an Independent Living Donor Advocate (ILDA) or an ILDA team. What is the primary role of the ILDA?

To ensure the living donor's best interests are protected and that their decision is informed and free from coercion. (Correct answer)
To determine the final medical and surgical suitability of the potential living donor.
To educate the transplant recipient about the risks associated with living donation.
To negotiate financial reimbursement for the living donor's travel and lodging expenses.

Correct answer: To ensure the living donor's best interests are protected and that their decision is informed and free from coercion.

The primary function of the Independent Living Donor Advocate (ILDA) is to advocate for the best interests of the living donor. This includes ensuring the donor understands the comprehensive risks and benefits, verifying that their decision is voluntary and free of coercion, and addressing their psychosocial and medical needs separately from the interests of the recipient.

Question 22: A transplant coordinator is providing discharge education to a kidney recipient who seems to agree with all instructions but is unable to accurately state their medication schedule. What is the MOST effective technique the coordinator should use to ensure comprehension and promote adherence?

Use the "teach-back" method, asking the patient to explain the medication plan in their own words. (Correct answer)
Refer the patient to the outpatient pharmacy for a consultation upon discharge.
Document that the patient received the education and schedule a follow-up call in one week.
Provide the patient with several detailed, pre-printed brochures about the medications.

Correct answer: Use the "teach-back" method, asking the patient to explain the medication plan in their own words.

The teach-back method is an evidence-based communication technique that assesses patient understanding by asking them to restate the information in their own words. It is a direct and effective way to confirm comprehension and correct any misunderstandings, which is crucial for complex medication regimens. Providing brochures is a passive method and does not confirm understanding. While a pharmacy consult is helpful, the coordinator has a direct responsibility to ensure understanding before discharge. Simply documenting the education without confirming comprehension is insufficient.

Question 23: Which of the following best describes the coordinator's role in addressing financial barriers identified during psychosocial assessment?

Deny listing to candidates without adequate insurance
Advise the patient to apply only after financial issues are fully resolved
Refer the patient to the transplant social worker and financial counselor for resource navigation (Correct answer)
Personally fund prescription medications for the patient

Correct answer: Refer the patient to the transplant social worker and financial counselor for resource navigation

The coordinator identifies financial barriers and facilitates referral to social work and financial counseling teams who can connect patients with assistance programs and insurance resources.

Question 24: What should be facilitated as part of waitlist management?

Removing candidates without proper documentation
Failing to record updated diagnostic and lab results
Failing to communicate with the local care provider
Maintaining listing status per OPTN policies (Correct answer)

Correct answer: Maintaining listing status per OPTN policies

Explanation: <br> Facilitating the maintenance of listing status per OPTN (Organ Procurement and Transplantation Network) policies is crucial in waitlist management for transplant candidates. This involves adhering to the established policies and procedures for listing candidates, documenting and recording updated diagnostic and lab results as required by OPTN, and ensuring that candidates remain eligible and properly documented on the waitlist. Failure to maintain listing status according to OPTN policies could result in candidates being inaccurately represented on the list or removed from it, affecting their chances of receiving a transplant in a timely manner.

Question 25: Under OPTN Policy, a pediatric patient listed Status 1A for heart transplant receives a local offer for a donor heart with a donor-recipient weight ratio of 3.8:1. The patient's cardiologist wants to accept. Which of the following represents the correct allocation consideration regarding size mismatch?

The offer can be accepted with medical justification documented, as oversized hearts can be used in pediatric patients with certain anatomical considerations (Correct answer)
The offer requires a variance request approved by the OPTN Thoracic Organ Transplantation Committee before acceptance
Acceptance is permitted only if the recipient has pulmonary hypertension, which would benefit hemodynamically from an oversized donor heart
The offer must be declined because OPTN policy prohibits donor-to-recipient weight ratios exceeding 3:1 for pediatric recipients

Correct answer: The offer can be accepted with medical justification documented, as oversized hearts can be used in pediatric patients with certain anatomical considerations

OPTN policy does not impose a hard cap on donor-to-recipient weight ratio for pediatric heart recipients in the same way it does for some other organs. Oversized donor hearts (including those with high weight ratios) can be used in pediatric recipients, particularly when anatomical constraints of the chest cavity are assessed and found acceptable. The cardiologist and surgical team exercise clinical judgment, and proper medical justification must be documented. No formal variance from the OPTN Thoracic Committee is required simply for size mismatch, and pulmonary hypertension is not a prerequisite for acceptance.

Question 26: A kidney transplant recipient on POD 1 receives mycophenolate mofetil (MMF) 1,500 mg BID. The patient's chart shows she was initiated on oral vancomycin preoperatively for recurrent C. difficile. The transplant coordinator should flag this combination because:

Oral vancomycin is systemically absorbed and inhibits CYP3A4, leading to dangerously elevated MMF plasma levels
Vancomycin potentiates MMF nephrotoxicity, increasing the risk of tubular necrosis in the newly transplanted kidney
Concurrent use of MMF and vancomycin dramatically increases the risk of BK virus nephropathy by over-immunosuppressing the patient
Oral vancomycin can significantly reduce MMF bioavailability by disrupting gut flora that convert MMF to its active metabolite, mycophenolic acid (Correct answer)

Correct answer: Oral vancomycin can significantly reduce MMF bioavailability by disrupting gut flora that convert MMF to its active metabolite, mycophenolic acid

MMF is a prodrug converted by gut esterases and enterohepatic recirculation — dependent on intestinal flora — to its active form, mycophenolic acid (MPA). Oral vancomycin, while minimally systemically absorbed, profoundly alters gut microbiota. This disruption can reduce enterohepatic recirculation of MPA, lowering the effective immunosuppressive exposure and increasing rejection risk. This is a clinically relevant pharmacokinetic interaction that transplant coordinators must recognize. Vancomycin does not cause nephrotoxicity when given orally (no systemic absorption), does not directly increase BK risk independent of total immunosuppression level, and does not inhibit CYP3A4 systemically.

Question 27: A kidney transplant coordinator is managing a highly sensitized patient (cPRA 99%) who has been waitlisted for 9 years. A deceased donor kidney becomes available with a negative virtual crossmatch. Before proceeding, the coordinator learns the donor had a remote history of treated Mycobacterium tuberculosis with documented cure 12 years ago. What is the most appropriate next step?

Decline the organ immediately, as any history of TB is an absolute contraindication to donation
Consult with infectious disease and proceed if recipient prophylactic isoniazid therapy is planned post-transplant (Correct answer)
Proceed with transplant without additional precautions since the infection was cured over a decade ago
Accept the organ only if the recipient's pre-transplant TB screening (IGRA or TST) is negative

Correct answer: Consult with infectious disease and proceed if recipient prophylactic isoniazid therapy is planned post-transplant

A history of treated and cured TB is not an absolute contraindication to organ donation. However, reactivation risk exists under immunosuppression. The appropriate approach is infectious disease consultation, and if the organ is accepted, the recipient should receive isoniazid prophylaxis post-transplant for 6–9 months. The recipient's own TB screening status does not determine acceptability of the donor organ — even a recipient with a positive IGRA can receive the organ with proper prophylaxis planning.

Question 28: A transplant coordinator receives a call from a journalist requesting confirmation that a celebrity is currently listed on the transplant waiting list. The coordinator neither confirms nor denies the information but mentions that 'all patients receive equal treatment regardless of status.' A compliance officer later flags this response. Why might this response be considered a HIPAA violation?

HIPAA prohibits all communication with journalists, even non-confirmatory responses
Confirming equal treatment implicitly acknowledges that the named individual is receiving treatment, which constitutes an unauthorized disclosure of PHI (Correct answer)
The statement violated HIPAA's minimum necessary standard by providing more information than required
The coordinator was required to directly deny the inquiry rather than offering a neutral statement

Correct answer: Confirming equal treatment implicitly acknowledges that the named individual is receiving treatment, which constitutes an unauthorized disclosure of PHI

Under HIPAA's Privacy Rule, even an implicit acknowledgment that someone is a patient constitutes disclosure of protected health information (PHI). Responding with 'all patients receive equal treatment' in reply to a question about a specific named individual implies that person is indeed a patient — an indirect but legally meaningful confirmation. The correct response is a blanket policy statement that does not reference the individual at all. HIPAA does not require direct denial, does not prohibit all journalist contact, and the minimum necessary standard applies to internal disclosures, not external inquiries.

Question 29: Which blood pressure threshold is most widely used as a contraindication to living kidney donation in an otherwise healthy candidate?

Any episode of elevated BP in the past year
BP consistently above 130/80 mmHg uncontrolled
BP above 120/80 mmHg on two readings
BP consistently above 140/90 mmHg despite optimal treatment with multiple agents (Correct answer)

Correct answer: BP consistently above 140/90 mmHg despite optimal treatment with multiple agents

Uncontrolled hypertension requiring multiple medications raises long-term renal risk for the donor and is generally considered a contraindication.

Question 30: A kidney transplant candidate is found to have significant peripheral vascular disease on evaluation. What is the most important implication for surgical planning?

Laparoscopic donor surgery is preferred
The patient needs a simultaneous pancreas transplant
Vascular surgeons must assess iliac vessel patency before listing (Correct answer)
The patient should undergo carotid endarterectomy first

Correct answer: Vascular surgeons must assess iliac vessel patency before listing

Peripheral vascular disease affecting iliac vessels can jeopardize anastomosis success; vascular assessment is mandatory to determine surgical feasibility.

Question 31: Under CMS CoPs, a transplant center must submit data to the OPTN for all of the following EXCEPT:

Potential donors who were not recovered (Correct answer)
Waitlisted candidates
Transplant recipients
Living donors

Correct answer: Potential donors who were not recovered

CMS CoPs require data submission for waitlisted candidates, recipients, and living donors, but potential donors who were not recovered are the OPO's reporting responsibility.

Question 32: Most U.S. hospital protocols for declaring brain death require which of the following?

A transplant coordinator and a neurologist acting together
One attending physician and written family consent
Two independent physicians, with the transplant team explicitly excluded from making the determination (Correct answer)
Three physicians including the transplant surgeon to confirm organ suitability

Correct answer: Two independent physicians, with the transplant team explicitly excluded from making the determination

Brain death declaration requires two independent physicians (at minimum one with neurological expertise) to prevent conflicts of interest. The transplant team is specifically excluded from the determination to maintain the ethical separation between donor care and recipient care.

Question 33: A 58-year-old patient with end-stage renal disease secondary to ANCA-associated vasculitis is being evaluated for kidney transplant. ANCA titers are currently undetectable on immunosuppressive therapy. Which factor most critically influences the transplant team's decision regarding timing of listing?

Duration of undetectable ANCA titers prior to listing, typically requiring ≥12 months of remission (Correct answer)
Discontinuation of all immunosuppression for 6 months to assess disease stability off therapy
Requiring a repeat kidney biopsy showing complete resolution of glomerulonephritis before listing
Mandatory plasmapheresis completion before transplant evaluation can proceed

Correct answer: Duration of undetectable ANCA titers prior to listing, typically requiring ≥12 months of remission

For patients with ANCA-associated vasculitis, most transplant centers require a sustained period of clinical remission—typically at least 12 months of undetectable disease activity on stable or minimal immunosuppression—before listing. This reduces the risk of post-transplant disease recurrence in the allograft. Repeat biopsy is not universally required if clinical remission is documented. Discontinuing immunosuppression to 'test' stability would be dangerous and counterproductive. Plasmapheresis is a treatment modality, not a universal pre-listing requirement.

Question 34: A heart transplant candidate with treatment-resistant major depressive disorder (MDD) is well-controlled on an MAOI and has been psychiatrically stable for 2 years. The transplant psychiatry consultant recommends listing. The psychosocial coordinator is aware that post-transplant immunosuppressants such as corticosteroids can exacerbate mood disorders. The coordinator's MOST appropriate action is to:

Accept the psychiatric consultant's recommendation without further coordination, as psychiatric decisions are outside the coordinator's scope
Recommend deferral because MDD is an absolute contraindication to heart transplantation
Recommend the patient switch from MAOI to an SSRI prior to listing to reduce drug interaction risk post-transplant
Incorporate a detailed post-transplant psychiatric monitoring and steroid-taper protocol into the care plan, ensuring cross-disciplinary communication between psychiatry, transplant medicine, and the patient (Correct answer)

Correct answer: Incorporate a detailed post-transplant psychiatric monitoring and steroid-taper protocol into the care plan, ensuring cross-disciplinary communication between psychiatry, transplant medicine, and the patient

Treatment-resistant MDD managed effectively is not an absolute contraindication. The coordinator's role at this juncture is to ensure proactive care coordination: building a post-transplant surveillance plan that addresses the known risk of corticosteroid-induced mood exacerbation, ensures psychiatric follow-up is embedded in the post-transplant protocol, and facilitates communication across disciplines. Recommending a medication switch is outside the coordinator's scope and potentially harmful. Passive acceptance of the consultant's note without integrating it into the care plan is a coordination failure.

Question 35: A heart transplant recipient is 11 years post-transplant with stable allograft function. Annual surveillance coronary angiography reveals new 40% stenosis in the LAD with diffuse vessel pruning characteristic of cardiac allograft vasculopathy (CAV). He is currently on cyclosporine, azathioprine, and pravastatin. Which modification to his immunosuppression regimen has the strongest evidence for slowing CAV progression at this stage?

Switch cyclosporine to tacrolimus to achieve better T-cell suppression
Convert azathioprine to everolimus (mTOR inhibitor) while reducing cyclosporine exposure (Correct answer)
Add mycophenolate mofetil to the existing regimen without other changes
Initiate high-dose methylprednisolone pulse therapy for 3 days

Correct answer: Convert azathioprine to everolimus (mTOR inhibitor) while reducing cyclosporine exposure

mTOR inhibitors (sirolimus or everolimus) have the strongest evidence base for slowing progression of established CAV. The SCHEDULE and NOCTET trials demonstrated that converting to everolimus with reduced CNI exposure reduces intimal thickening progression on intravascular ultrasound and may modestly improve outcomes in established CAV. Switching CNI class (cyclosporine → tacrolimus) does not address the antiproliferative need. Adding MMC without structural change doesn't address the vasoproliferative mechanism. Pulse steroids are irrelevant to CAV pathophysiology, which is immune-mediated intimal smooth muscle proliferation.

Question 36: A kidney transplant recipient in the ICU has urine output of 800 mL/hr in the first postoperative hour. What is the most appropriate initial management?

Restrict fluids to prevent fluid overload
Replace urine output mL-for-mL with IV fluids (Correct answer)
Notify the surgeon immediately for re-exploration
Administer furosemide to reduce output

Correct answer: Replace urine output mL-for-mL with IV fluids

Brisk diuresis after kidney transplant requires mL-for-mL fluid replacement to maintain adequate perfusion and prevent dehydration.

Question 37: During a pre-transplant psychosocial evaluation for a lung transplant candidate, the evaluating social worker identifies that the patient's designated primary caregiver—her adult son—has active moderate-to-severe alcohol use disorder that he minimizes. The patient states she has no other social support and insists her son will 'pull it together.' How should the transplant team most appropriately address this finding?

Accept the patient's assessment and list her, noting that caregiver adequacy is the patient's personal responsibility post-transplant
Engage the patient and son in a structured caregiver readiness intervention, set benchmarks for caregiver sobriety and skill acquisition, and reassess prior to listing (Correct answer)
Decline listing permanently because an impaired caregiver constitutes a non-modifiable psychosocial contraindication
List the patient conditionally and reassess caregiver status only if a post-transplant crisis arises

Correct answer: Engage the patient and son in a structured caregiver readiness intervention, set benchmarks for caregiver sobriety and skill acquisition, and reassess prior to listing

Robust caregiver support is a well-established requirement for lung transplant listing because of the intensive post-operative demands. An impaired caregiver is a serious but potentially modifiable psychosocial risk factor—not an automatic permanent contraindication. The evidence-based approach is to clearly communicate the concern to both the patient and caregiver, offer structured intervention (e.g., addiction treatment referral for the son, caregiver training, identification of backup supports), and establish measurable benchmarks before a final listing decision. Accepting the situation without action ignores a significant risk; permanent declination without attempting remediation is disproportionate; and conditional listing without pre-transplant resolution of the caregiver issue is premature.

Question 38: During a hospital accreditation survey, a Joint Commission surveyor asks to review the transplant program's QAPI records for the past 12 months, including minutes from mortality and morbidity conferences. The transplant medical director refuses, citing peer review privilege under state law. The coordinator is caught between the medical director and the surveyor. Which of the following BEST reflects the correct regulatory and accreditation framework?

The transplant coordinator should provide the full QAPI records to the surveyor, as Joint Commission accreditation supersedes state peer review protections
CMS Conditions of Participation override state peer review privilege entirely, requiring full disclosure of all M&M conference minutes to any accrediting body
Joint Commission standards require programs to demonstrate a functioning QAPI process; while specific deliberations may be protected, the program must provide evidence of the process itself (e.g., meeting frequency, topics reviewed, action items taken) without necessarily disclosing privileged deliberations (Correct answer)
State peer review privilege fully shields all QAPI documentation from Joint Commission review, and the surveyor must accept the medical director's assertion without further inquiry

Correct answer: Joint Commission standards require programs to demonstrate a functioning QAPI process; while specific deliberations may be protected, the program must provide evidence of the process itself (e.g., meeting frequency, topics reviewed, action items taken) without necessarily disclosing privileged deliberations

Joint Commission standards (specifically the transplant-specific standards and QAPI requirements) require programs to demonstrate that a robust quality improvement process exists, but they do not require disclosure of privileged deliberations in states with peer review protection statutes. The correct approach is to provide meta-level evidence of QAPI functioning — meeting logs, action item tracking, policy updates — while asserting privilege over specific case deliberations. Neither blanket refusal nor full disclosure is appropriate; the answer requires navigating both frameworks simultaneously. The coordinator should involve the hospital's legal counsel and compliance officer in real time.

Question 39: A living kidney donor is approved and surgery is scheduled. Three days before the procedure, the transplant coordinator learns from a social worker that the donor privately told a family friend she feels 'pressured' by her family but doesn't want to disappoint anyone. The donor has not disclosed this to the independent donor advocate (IDA) or transplant team. Under OPTN Policy 18, what is the coordinator's MOST appropriate action?

Cancel the surgery immediately and permanently withdraw the donor from candidacy based on the third-party report
Consult the recipient's transplant surgeon to jointly decide whether surgery should proceed based on the clinical team's assessment of donor willingness
Notify the independent donor advocate (IDA) immediately and ensure the donor has a private, confidential reassessment opportunity before surgery proceeds (Correct answer)
Document the disclosure in the chart and allow the donor to raise concerns independently at the pre-op visit

Correct answer: Notify the independent donor advocate (IDA) immediately and ensure the donor has a private, confidential reassessment opportunity before surgery proceeds

OPTN Policy 18 mandates that living donor programs ensure donors have ongoing access to independent advocacy and that voluntariness is actively protected throughout the process. A third-party report of coercion — even if unconfirmed — obligates the coordinator to trigger the IDA pathway immediately and create a confidential space for the donor to reassess without family or recipient pressure. Waiting for the donor to self-disclose is insufficient when the coordinator has been put on notice; involving the recipient's surgeon violates the firewall between donor and recipient care teams.

Question 40: A kidney transplant recipient at 3 years post-transplant has a serum creatinine that has slowly risen from 1.2 to 2.1 mg/dL over 6 months. The most likely diagnosis is:

Acute cellular rejection
Chronic allograft nephropathy (Correct answer)
Calcineurin inhibitor toxicity
Urinary tract infection

Correct answer: Chronic allograft nephropathy

Slowly progressive decline in renal function years after transplant is the hallmark of chronic allograft nephropathy (interstitial fibrosis/tubular atrophy).

Question 41: A 44-year-old female lung transplant recipient 9 years post-transplant presents with FEV1 declining to 52% of her personal best over 6 months, with no improvement after augmented infection surveillance and treatment. High-resolution CT shows air trapping and bronchiectasis without significant bronchial wall thickening. BAL shows no organisms, and transbronchial biopsy shows no acute rejection. She has a history of two prior acute rejection episodes (A2). Which phenotype of chronic lung allograft dysfunction (CLAD) does this pattern represent, and what is the implication for treatment?

Bronchiolitis obliterans syndrome (BOS); likely to respond to azithromycin and fluoroquinolone therapy (Correct answer)
Restrictive allograft syndrome (RAS); associated with worse prognosis and poor response to azithromycin compared to BOS
Neutrophilic reversible allograft dysfunction (NRAD); requires augmented immunosuppression reduction
Azithromycin-responsive allograft dysfunction (ARAD); first-line treatment is azithromycin alone

Correct answer: Bronchiolitis obliterans syndrome (BOS); likely to respond to azithromycin and fluoroquinolone therapy

The pattern described — progressive obstructive decline (FEV1 drop), air trapping, bronchiectasis on CT, absence of consolidation or ground-glass opacity, and no restrictive pattern — is characteristic of BOS (Bronchiolitis Obliterans Syndrome), the obstructive CLAD phenotype. BOS has a better prognosis than RAS and is more likely to stabilize with azithromycin (anti-inflammatory), fluoroquinolones, and optimized immunosuppression. RAS presents with restrictive physiology (TLC reduction) and peripheral/pleural CT changes. NRAD is a subset of BOS with BAL neutrophilia that reverses with azithromycin. The distinction matters because RAS has a median survival of ~1 year versus ~3–4 years for BOS after diagnosis.

Question 42: A heart transplant recipient 8 years post-transplant undergoes routine surveillance coronary angiography, which shows diffuse, concentric luminal narrowing affecting the distal vessels bilaterally with no focal stenoses. The patient is asymptomatic and has a normal resting ejection fraction. Which statement about management is MOST accurate?

Retransplantation is contraindicated in cardiac allograft vasculopathy regardless of severity
Proliferation signal inhibitor conversion (e.g., everolimus) may slow progression but renal function must be assessed first (Correct answer)
Percutaneous coronary intervention with drug-eluting stents is the preferred treatment given the pattern of disease
High-dose statin therapy alone is sufficient to halt progression in diffuse CAV

Correct answer: Proliferation signal inhibitor conversion (e.g., everolimus) may slow progression but renal function must be assessed first

Cardiac allograft vasculopathy (CAV) is a diffuse, concentric, immune-mediated process affecting the entire coronary tree — unlike native atherosclerosis. mTOR inhibitors (sirolimus, everolimus) have demonstrated angiographic slowing of CAV progression and are a guideline-supported strategy. However, their antiproliferative effects also impair wound healing and can worsen proteinuria/renal function, so baseline renal assessment is essential before conversion. PCI is limited by the diffuse distal nature of CAV. Retransplantation is considered for advanced CAV but is not universally contraindicated. Statins reduce events but do not halt progression alone.

Question 43: Which step is involved in the assessment of donor and/or candidate suitability and adherence?

Ignoring the importance of adherence to the transplant regimen
Failing to communicate findings to the transplant team
Providing inaccurate information to the candidate or donor
Assessing the candidate's commitment and suitability (Correct answer)

Correct answer: Assessing the candidate's commitment and suitability

Explanation: <br> Assessing the candidate's commitment and suitability involves evaluating their willingness and ability to adhere to the transplant regimen, follow medical advice, and participate in long-term post-transplant care. This step is crucial in determining the suitability of the candidate or donor for transplantation.

Question 44: In liver transplant recipients, hepatic artery thrombosis (HAT) occurring beyond 30 days post-transplant (late HAT) most commonly presents with which clinical pattern, distinguishing it from early HAT?

Recurrent biliary strictures and bilomas without systemic sepsis (Correct answer)
Isolated hyperbilirubinemia with preserved synthetic function
Asymptomatic elevation of liver enzymes detected incidentally on routine labs
Acute fulminant hepatic failure requiring urgent re-transplantation

Correct answer: Recurrent biliary strictures and bilomas without systemic sepsis

Late HAT (>30 days post-transplant) typically presents insidiously with recurrent biliary complications — bile duct strictures and bilomas — because the bile ducts depend entirely on hepatic artery blood supply. By this stage, collateral circulation has usually developed enough to prevent fulminant hepatic necrosis, so the graft survives but bile duct ischemia predominates. Early HAT, by contrast, commonly causes acute graft failure or sepsis from biliary necrosis without established collaterals. Asymptomatic enzyme elevation and isolated hyperbilirubinemia are possible but less characteristic than the biliary stricture/biloma pattern.

Question 45: A transplant coordinator receives a kidney offer for a highly sensitized candidate with a PRA of 98%. What is the most critical pre-acceptance step?

Assessment of the donor's KDPI score only
Review of the candidate's social support documentation
Confirmation of the candidate's insurance authorization
Virtual or prospective crossmatch to assess compatibility (Correct answer)

Correct answer: Virtual or prospective crossmatch to assess compatibility

For highly sensitized candidates, a virtual crossmatch using donor HLA typing and recipient antibody profile is essential before acceptance to avoid hyperacute rejection.

Question 46: A critical component of patient education involves teaching the signs and symptoms of acute rejection. For a lung transplant recipient, which of the following symptom clusters should be taught as a reason to contact the transplant center immediately?

Flank pain, decreased urine output, and swelling in the legs.
New-onset tremor, headache, and increased thirst.
Abdominal bloating, nausea, and yellowing of the skin.
Progressive shortness of breath, a persistent dry cough, and a low-grade fever. (Correct answer)

Correct answer: Progressive shortness of breath, a persistent dry cough, and a low-grade fever.

The symptoms listed in D (shortness of breath, cough, fever) are classic signs of a potential pulmonary issue, which could indicate either acute rejection or infection in a lung transplant recipient. These symptoms warrant immediate medical attention. The symptoms in A are more typical of calcineurin inhibitor toxicity. The symptoms in B are classic signs of kidney rejection or dysfunction. The symptoms in C are indicative of liver dysfunction.

Question 47: A transplant program receives a directed donation offer from a donor family who specifies that their loved one's organs may NOT go to recipients of a particular ethnicity. Under current UNOS/OPTN policy, what must the OPO and transplant coordinator do?

Honor the family's wishes as part of respecting donor autonomy, provided the restriction is documented
Accept the restriction only if the medical urgency of waiting candidates overrides the ethical concern
Decline to proceed with the donation under those conditions, as OPTN policy prohibits allocation restrictions based on race or ethnicity (Correct answer)
Accept the organs under a 'conditional donation' classification and allocate accordingly within the restricted pool

Correct answer: Decline to proceed with the donation under those conditions, as OPTN policy prohibits allocation restrictions based on race or ethnicity

OPTN Policy explicitly prohibits discrimination in organ allocation based on race, color, national origin, sex, age, disability, or religion. Conditional donations that impose discriminatory restrictions on who may receive organs are not permitted within the OPTN system. The OPO must decline to proceed under those conditions. There is no 'conditional donation' classification that accommodates racially restrictive directives, and medical urgency does not override the non-discrimination mandate.

Question 48: A renal transplant coordinator is reviewing labs on a deceased-donor kidney recipient on POD 3. Tacrolimus trough is 18.2 ng/mL (target 10-15), creatinine is 4.1 mg/dL (non-oliguric), urine output is 55 mL/hr, and there is no fever. Doppler shows RI of 0.88. Which additional finding would MOST definitively differentiate calcineurin inhibitor nephrotoxicity from acute T-cell mediated rejection as the cause of graft dysfunction?

Response to a 1L IV normal saline challenge over 2 hours
Percutaneous allograft biopsy showing tubular vacuolization without intimal arteritis or tubulitis (Correct answer)
Reduction in creatinine after holding tacrolimus for 48 hours
24-hour urine protein of 3.2 g demonstrating proteinuria

Correct answer: Percutaneous allograft biopsy showing tubular vacuolization without intimal arteritis or tubulitis

While holding CNI and observing creatinine trends (option D) is clinically practiced, it is not definitive — rejection can also partially respond to CNI dose reduction if adequate immunosuppression persists. Percutaneous biopsy with Banff criteria interpretation is the gold standard: CNI toxicity shows isometric tubular vacuolization, striped interstitial fibrosis, and arteriolar hyalinosis without significant inflammation, tubulitis, or intimal arteritis — findings that directly exclude T-cell mediated rejection. A saline challenge tests volume depletion (prerenal), not the CNI-vs-rejection distinction. Proteinuria points toward other pathology (glomerulopathy, chronic injury) and is nonspecific at POD 3. Empiric creatinine response to CNI reduction is useful but not definitive.

Question 49: During long-term follow-up, a lung transplant recipient 5 years post-bilateral lung transplant has FEV1 that has declined 28% from baseline over 18 months despite optimization of tacrolimus and azathioprine. CT chest shows air trapping and bronchiectasis without neutrophilic airway inflammation on BAL. Spirometry shows an obstructive pattern. Which diagnosis and management approach is most appropriate?

Bronchiolitis obliterans syndrome (BOS) Grade 2; add azithromycin, consider montelukast, and evaluate for extra-esophageal GERD with pH-impedance study and possible fundoplication (Correct answer)
Restrictive allograft syndrome (RAS); initiate high-dose pulse methylprednisolone and add pirfenidone to slow fibrotic progression
Acute fibrinous organizing pneumonia (AFOP); bronchoscopic cryobiopsy is required for definitive diagnosis before initiating augmented immunosuppression
Lymphocytic bronchiolitis (LB); increase tacrolimus target to 12–15 ng/mL and switch azathioprine to mycophenolate mofetil as LB is highly steroid-responsive at this stage

Correct answer: Bronchiolitis obliterans syndrome (BOS) Grade 2; add azithromycin, consider montelukast, and evaluate for extra-esophageal GERD with pH-impedance study and possible fundoplication

The presentation — progressive obstructive FEV1 decline >20% from baseline over 18 months, air trapping, bronchiectasis, and absent neutrophilic BAL inflammation — is consistent with BOS Grade 2 (CLAD phenotype). Azithromycin has anti-inflammatory and immunomodulatory properties and is standard add-on therapy for BOS. GERD is a well-established risk factor for BOS/CLAD progression; pH-impedance monitoring and surgical fundoplication are evidence-based interventions shown to slow BOS progression. RAS presents with a restrictive pattern and subpleural/peribronchovascular fibrosis. Lymphocytic bronchiolitis is a precursor lesion, not a 5-year late presentation with established obstruction.

Question 50: During an internal audit, a transplant coordinator finds that the program has been listing candidates with a diagnosis of 'hepatocellular carcinoma within Milan criteria' using MELD exception points without submitting cases to the regional review board within the OPTN-required window. Some listings are 6 months old without RRB submission. What is the MOST serious regulatory consequence specific to this finding?

The program's HCC exception points for all currently listed HCC candidates will be automatically rescored to MELD 6 by the UNOS system
Candidates may be relisted at their original MELD without exception points, and the program may receive a compliance letter from MPSC (Correct answer)
The program must immediately remove all affected candidates from the waitlist pending RRB review
CMS will issue a deficiency citation under CoP §482.94 for failure to maintain accurate waitlist data

Correct answer: Candidates may be relisted at their original MELD without exception points, and the program may receive a compliance letter from MPSC

Under OPTN policy, HCC exception requests not submitted to the Regional Review Board within the required window (typically within 90 days of listing for initial requests) may result in candidates losing their exception points and being relisted at their calculated MELD score. Administratively, the program may also receive MPSC compliance correspondence. Mass waitlist removal is not the automatic consequence, CMS CoP citations are separate from OPTN policy enforcement, and UNOS does not automatically reset scores to MELD 6 — the consequence is reversion to calculated MELD, not a fixed floor score.

Question 51: On POD 2 following a simultaneous pancreas-kidney transplant (SPK), the patient develops a serum amylase of 2,800 U/L and lipase of 4,100 U/L with increasing abdominal tenderness. The transplant coordinator anticipates the surgical team will FIRST order:

Empiric broad-spectrum antibiotics and total parenteral nutrition for presumed graft pancreatitis
ERCP to rule out anastomotic leak at the exocrine drainage site
CT angiography of the abdomen and pelvis with IV contrast to evaluate pancreatic graft perfusion and exclude vascular thrombosis (Correct answer)
Urgent return to OR for pancreatic graft pancreatectomy given the severity of enzyme elevation

Correct answer: CT angiography of the abdomen and pelvis with IV contrast to evaluate pancreatic graft perfusion and exclude vascular thrombosis

Elevated pancreatic enzymes in the early post-SPK period may represent preservation/reperfusion pancreatitis, but vascular thrombosis — particularly venous thrombosis — is an early catastrophic complication that must be excluded urgently. CT angiography is the first-line imaging to assess graft perfusion and detect vascular compromise before any other intervention. ERCP is inappropriate in early postoperative SPK. Empiric treatment without ruling out thrombosis risks irreversible graft loss. Pancreatectomy without imaging confirmation of thrombosis would be premature.

Question 52: Which of the following post-transplant infections is considered a 'late' infection occurring more than 6 months post-transplant in a stable recipient with reduced immunosuppression?

Donor-derived bacteremia in the first week
Surgical wound infection
CMV primary disease in a D+/R− recipient
Community-acquired pneumonia and late viral infections (Correct answer)

Correct answer: Community-acquired pneumonia and late viral infections

Late infections (>6 months post-transplant) in stable recipients with tapering immunosuppression are typically community-acquired, similar to the general immunocompromised population.

Question 53: A heart transplant recipient 11 years post-transplant undergoes routine surveillance coronary angiography and is found to have cardiac allograft vasculopathy (CAV) classified as ISHLT Grade 3 with a resting hemodynamic compromise. Despite optimized medical therapy including a statin and diltiazem, ejection fraction has declined to 30%. The patient has no other significant comorbidities. Which is the most appropriate next intervention?

Conversion from calcineurin inhibitor to everolimus to halt CAV progression
Percutaneous coronary intervention (PCI) with drug-eluting stents to the most significant lesion
Implantation of a left ventricular assist device (LVAD) as destination therapy
Listing for re-transplantation (retransplantation) (Correct answer)

Correct answer: Listing for re-transplantation (retransplantation)

ISHLT CAV Grade 3 with hemodynamic compromise and systolic dysfunction refractory to medical therapy in an otherwise suitable candidate meets criteria for retransplantation, which is the only definitive treatment for severe CAV. PCI is palliative and insufficient for diffuse CAV Grade 3. mTOR inhibitor conversion can slow CAV progression but is ineffective for established severe disease with graft failure. LVAD as destination therapy (not bridge to retransplant) would be considered only if the patient is not a retransplant candidate, as retransplantation offers superior long-term outcomes in appropriate candidates.

Question 54: In lung transplant recipients, the most common manifestation of chronic allograft dysfunction is a progressive, irreversible airflow obstruction. What is the clinical term for this condition?

Post-transplant Lymphoproliferative Disorder (PTLD)
Bronchiolitis Obliterans Syndrome (BOS) (Correct answer)
Acute Cellular Rejection
Restrictive Allograft Syndrome (RAS)

Correct answer: Bronchiolitis Obliterans Syndrome (BOS)

Bronchiolitis Obliterans Syndrome (BOS) is the most common form of chronic lung allograft dysfunction (CLAD) and a leading cause of late graft failure. It is characterized by inflammation and fibrosis of the small airways, leading to a progressive and irreversible decline in expiratory airflow, measured by FEV1. RAS is a less common, restrictive form of CLAD.

Question 55: A lung transplant coordinator is reviewing a bilateral lung offer for a recipient with cystic fibrosis. The donor PaO₂/FiO₂ ratio is 280 mmHg on FiO₂ 1.0 with PEEP 5 cmH₂O. Bronchoscopy shows moderate purulent secretions bilaterally. Chest X-ray has a small right lower lobe infiltrate. Procurement team reports lungs are 'pink and well-inflated' on inspection. What is the MOST appropriate recommendation?

Accept the right lung only; decline the left due to bilateral purulent secretions
Accept the offer — bronchoscopic appearance and CXR infiltrate are common in mechanically ventilated donors and should not preclude transplant given favorable direct inspection (Correct answer)
Decline the offer — a P/F ratio below 300 on FiO₂ 1.0 is an absolute contraindication for lung transplant
Request bronchoscopic cultures and accept only if gram stain shows no organisms

Correct answer: Accept the offer — bronchoscopic appearance and CXR infiltrate are common in mechanically ventilated donors and should not preclude transplant given favorable direct inspection

Extended criteria lung donors are increasingly accepted at experienced centers. A P/F ratio of 280 is below the traditional 300 threshold but is not an absolute contraindication, particularly when direct inspection is favorable. Purulent secretions and small infiltrates are common in mechanically ventilated donors and do not independently preclude transplant — donor cultures are sent and recipient antibiotic prophylaxis is adjusted accordingly. The MOST appropriate action is to accept based on favorable gross inspection, with culture-directed antibiotic coverage. Unilateral acceptance based on secretion distribution is not standard practice for bilateral CF recipients. Absolute P/F cutoffs have been abandoned in contemporary practice at high-volume centers.

Question 56: The family of a brain-dead patient wishes to direct the donation of their loved one's kidney to a specific, unrelated friend who is on the national waiting list. According to Organ Procurement and Transplantation Network (OPTN) policy, this action is:

Generally permitted, provided the intended recipient is a registered candidate on the waiting list. (Correct answer)
Permitted only if the intended recipient is at the top of the match run for that organ.
Allowed only if the recipient is a first-degree relative of the donor.
Strictly prohibited to ensure fairness to all on the waitlist.

Correct answer: Generally permitted, provided the intended recipient is a registered candidate on the waiting list.

OPTN policy defines directed donation as the allocation of a deceased or living donor organ to a specific candidate named by the person authorizing the donation. This is generally permitted for deceased donors, as long as the intended recipient is on the waiting list. If the organ is not a match for the specified individual, it is then offered to the next person on the standard match run.

Question 57: Annual inactivated influenza vaccination is recommended for transplant recipients primarily because:

Influenza infection can trigger acute rejection and cause severe disease in immunocompromised hosts (Correct answer)
It prevents CMV reactivation
It is required by UNOS policy
It is mandated by Medicare conditions of participation

Correct answer: Influenza infection can trigger acute rejection and cause severe disease in immunocompromised hosts

Influenza can cause severe illness, pneumonia, and may trigger immune activation leading to acute rejection in transplant recipients, making annual vaccination critical.

Question 58: A 45-year-old living kidney donor candidate has a BMI of 31 and is found to have impaired fasting glucose (IFG) with a fasting glucose of 108 mg/dL on two separate occasions. HbA1c is 5.8%. The candidate's first-degree relatives include a parent with type 2 diabetes. Under KDIGO living donor guidelines, which statement BEST characterizes this candidate's candidacy?

IFG without overt diabetes is not a recognized risk factor in living donor assessment guidelines
The HbA1c of 5.8% falls below the prediabetes threshold, so metabolic risk is not disqualifying
Donation is acceptable if the candidate agrees to a structured weight-loss program prior to surgery
Donation is relatively contraindicated; the combination of IFG, elevated HbA1c, obesity, and family history significantly increases lifetime risk of ESRD post-donation (Correct answer)

Correct answer: Donation is relatively contraindicated; the combination of IFG, elevated HbA1c, obesity, and family history significantly increases lifetime risk of ESRD post-donation

KDIGO 2017 guidelines emphasize that prediabetes (IFG or IGT), particularly when combined with obesity (BMI ≥30), family history of T2DM, and elevated HbA1c (5.7–6.4%), creates a cumulative risk profile that substantially increases lifetime ESRD risk post-donation. In aggregate, this candidate has four independent prediabetic risk markers, making donation relatively contraindicated per KDIGO. Weight loss alone does not eliminate this risk sufficiently. An HbA1c of 5.8% IS within the prediabetes range (5.7–6.4%).

Question 59: A transplant coordinator is reviewing immunosuppression for a pancreas-kidney transplant recipient who is 18 months post-transplant and has developed new-onset insulin-requiring diabetes (NODAT) despite a previously functioning pancreas graft. C-peptide is detectable at 0.6 ng/mL (low-normal). Current immunosuppression: tacrolimus trough 9 ng/mL, MMF 750 mg BID, prednisone 5 mg daily. Pancreas biopsy reveals diffuse islet vacuolization with no evidence of rejection. Which etiology and management strategy is MOST appropriate?

Tacrolimus-induced direct islet beta-cell toxicity causing impaired insulin secretion — consider converting to cyclosporine or reducing tacrolimus with addition of a low-dose mTOR inhibitor (Correct answer)
Chronic allograft rejection causing progressive islet loss — augment immunosuppression with pulse steroids and add belatacept
CMV pancreatitis causing islet inflammation — obtain CMV PCR and initiate ganciclovir empirically
Recurrent autoimmune diabetes (type 1 recurrence) attacking the donor pancreas — initiate anti-CD3 therapy (teplizumab) to halt immune-mediated destruction

Correct answer: Tacrolimus-induced direct islet beta-cell toxicity causing impaired insulin secretion — consider converting to cyclosporine or reducing tacrolimus with addition of a low-dose mTOR inhibitor

Islet vacuolization on biopsy in the absence of rejection findings is the pathological hallmark of calcineurin inhibitor (CNI) — particularly tacrolimus — mediated islet toxicity. Tacrolimus interferes with insulin gene transcription and impairs beta-cell function in a dose-dependent manner; high-level vacuolization correlates with elevated trough exposure. Management involves reducing tacrolimus exposure, often by converting to cyclosporine (which has lower diabetogenic risk) or by adding an mTOR inhibitor (everolimus/sirolimus) to allow tacrolimus dose reduction while maintaining immunosuppression adequacy. Recurrent T1D is possible but would show insulitis (lymphocytic infiltration of islets) on biopsy, not vacuolization, and would require anti-islet antibody testing. Rejection causing NODAT would show typical rejection histology. CMV pancreatitis causes ductal/acinar inflammation with viral inclusions, not isolated islet vacuolization.

Question 60: A heart transplant patient on tacrolimus develops new-onset diabetes mellitus (NODAT) 8 months post-transplant. The team considers switching to a cyclosporine-based regimen to improve glucose metabolism. Which statement MOST accurately reflects the comparative diabetogenicity of these agents?

Cyclosporine is more diabetogenic than tacrolimus because it preferentially binds cyclophilin D in beta cell mitochondria, impairing ATP production required for insulin secretion
Tacrolimus and cyclosporine are equipotent in causing NODAT because both equally inhibit calcineurin in pancreatic beta cells
The diabetogenic risk is equivalent between agents, and switching to cyclosporine provides no metabolic benefit; sirolimus would be the preferred alternative
Tacrolimus is significantly more diabetogenic than cyclosporine, primarily due to its greater inhibition of insulin gene transcription via NFAT suppression in beta cells and direct mitochondrial toxicity (Correct answer)

Correct answer: Tacrolimus is significantly more diabetogenic than cyclosporine, primarily due to its greater inhibition of insulin gene transcription via NFAT suppression in beta cells and direct mitochondrial toxicity

Tacrolimus carries a significantly higher risk of NODAT compared to cyclosporine (approximately 2–4× greater risk in meta-analyses). Both agents inhibit calcineurin via their respective immunophilin complexes (FKBP12 for tacrolimus, cyclophilin for cyclosporine), suppressing NFAT-driven insulin gene transcription in pancreatic beta cells. However, tacrolimus produces more profound beta cell toxicity — including mitochondrial dysfunction and reduced insulin secretion — at clinically used concentrations. Switching to cyclosporine is a recognized strategy to improve NODAT in appropriate candidates, though it comes with trade-offs in rejection risk.

Question 61: A family asks why their transplanted relative must avoid raw or undercooked seafood. What is the best explanation?

Raw seafood causes tacrolimus toxicity
Immunosuppression increases susceptibility to foodborne pathogens (Correct answer)
Seafood interferes with anti-rejection lab results
Raw seafood elevates creatinine levels

Correct answer: Immunosuppression increases susceptibility to foodborne pathogens

Immunosuppressed transplant recipients are at high risk for severe infections from pathogens in raw or undercooked foods.

Question 62: A critically ill patient has no advance directive and no identifiable next of kin. Who typically holds legal authority to consent for organ donation in this situation?

A court-appointed guardian or, in some states, the hospital administrator as authorized by statute (Correct answer)
No donation can occur without next-of-kin consent in all US states
The OPO coordinator, as the donation specialist
The attending physician, as the responsible clinician

Correct answer: A court-appointed guardian or, in some states, the hospital administrator as authorized by statute

When no surrogate is available, some states authorize a court-appointed guardian or hospital authority to consent for donation under specific statutory provisions.

Question 63: A coordinator at a transplant center is reviewing a potential living kidney donor who is a non-U.S. citizen visiting on a tourist visa. The intended recipient is the donor's sibling, who is a U.S. citizen and a current patient of the program. Which regulatory consideration is MOST directly implicated in the evaluation of this living donor?

CMS Conditions of Participation requiring documentation that the donor's immigration status does not create undue financial burden on the transplant program
The requirement under 42 CFR §121.4 that UNOS verify the legal status of all international living donors before approving the transplant
OPTN Policy 14.4, which prohibits transplant programs from accepting living donors who are not lawful permanent residents or citizens
The National Organ Transplant Act (NOTA) prohibition on valuable consideration, which requires particular scrutiny when an international donor's travel and lodging expenses are reimbursed by the recipient (Correct answer)

Correct answer: The National Organ Transplant Act (NOTA) prohibition on valuable consideration, which requires particular scrutiny when an international donor's travel and lodging expenses are reimbursed by the recipient

NOTA (42 U.S.C. §274e) prohibits the transfer of human organs for valuable consideration. When an international living donor travels to the U.S. specifically to donate, programs must carefully document that any reimbursement of expenses (travel, lodging, lost wages) is genuinely compensatory and not a disguised payment for the organ. OPTN policy does not prohibit non-citizen living donors; immigration status alone does not disqualify a donor. CMS does not have a specific CoP requirement about donor immigration status, and UNOS does not independently verify immigration status before transplant approval.

Question 64: Which standardized tool is most commonly used by transplant coordinators to screen for depression in transplant candidates?

Patient Health Questionnaire-9 (PHQ-9) (Correct answer)
Geriatric Depression Scale (GDS)
Beck Anxiety Inventory (BAI)
Minnesota Multiphasic Personality Inventory (MMPI)

Correct answer: Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 is the most widely validated and used screening tool for depression in the transplant population across US centers.

Question 65: A potential living kidney donor is found to have a solitary renal artery on the intended donor kidney but duplicated renal arteries on the contralateral kidney. From a surgical anatomy standpoint, which kidney should preferentially be used for donation, and why?

The kidney with duplicated arteries, because more complex anatomy on the donated organ is acceptable as long as the donor retains the simpler kidney (Correct answer)
The kidney with duplicated arteries should be donated to maximize graft mass for the recipient
The kidney with the solitary artery, because it poses a lower technical risk for the recipient's vascular anastomosis and the donor retains the kidney with the less complex vasculature
Either kidney is equivalent; vascular anatomy has no bearing on donor kidney selection

Correct answer: The kidney with duplicated arteries, because more complex anatomy on the donated organ is acceptable as long as the donor retains the simpler kidney

Standard surgical selection principles dictate that the donor should retain the kidney that is functionally superior or anatomically safer — meaning the simpler kidney stays with the donor. However, the dominant consideration here is that the kidney with duplicated arteries, when donated, creates added complexity for the recipient's anastomosis and modestly increases warm ischemia time and technical failure risk. Therefore, the preferred approach is to leave the donor with the simpler (solitary artery) kidney and donate the anatomically complex one — as long as that complexity is manageable for the recipient surgical team. Answer A correctly identifies this principle: the donor retains the simpler anatomy.

Question 66: A brain-dead patient's legally designated healthcare proxy consents to donation, but adult children object. Who has legal authority to authorize donation?

The attending physician, because the patient is brain dead
The designated healthcare proxy, as legally authorized decision-maker (Correct answer)
The adult children, because they are next of kin
The hospital ethics committee, which must resolve family disputes

Correct answer: The designated healthcare proxy, as legally authorized decision-maker

A legally designated healthcare proxy holds decision-making authority and supersedes next-of-kin objections.

Question 67: During the psychosocial evaluation of a living donor candidate, which finding would most likely result in exclusion from donation?

Mild anxiety about the surgery
History of resolved depression with stable medications
Active untreated psychiatric disorder affecting decision-making (Correct answer)
Moderate concern about recovery time

Correct answer: Active untreated psychiatric disorder affecting decision-making

An active untreated psychiatric disorder that impairs decision-making capacity disqualifies a candidate because informed consent requires intact judgment.

Question 68: During psychosocial evaluation of a liver transplant candidate with alcohol-associated liver disease, the social worker documents that the patient has 7 months of verified sobriety, strong social support, no prior rehabilitation admissions, and a SIPAT score of 28. The transplant psychiatrist recommends listing with conditions. Under AASLD consensus criteria, which element MOST strengthens a candidate's long-term sobriety prognosis and is specifically weighted in structured psychosocial tools like the SIPAT?

Duration of pre-transplant abstinence exceeding 6 months as a standalone predictor
Absence of liver-related hospitalizations during the abstinence period
Acknowledgment of alcoholism as a disease combined with insight into relapse triggers, support system stability, and absence of other substance use disorders (Correct answer)
Completion of at least one formal inpatient rehabilitation program prior to evaluation

Correct answer: Acknowledgment of alcoholism as a disease combined with insight into relapse triggers, support system stability, and absence of other substance use disorders

Research consistently shows that duration of abstinence alone (the '6-month rule') is a weak standalone predictor of post-transplant relapse. The SIPAT (Stanford Integrated Psychosocial Assessment for Transplant) and similar validated tools weight multiple composite factors: insight into the disease and personal triggers, readiness for behavior change, stability and quality of social support, absence of polysubstance use, prior treatment engagement, and psychiatric comorbidity. High SIPAT scores (≥21 is 'high risk') reflect deficits across these domains. A score of 28 on the SIPAT indicates significant psychosocial risk and warrants listing with conditions such as mandatory addiction counseling, random toxicology screening, and sponsor verification — not automatic denial. Insight and multi-domain stability predict outcomes more reliably than abstinence duration alone.

Question 69: A pediatric liver transplant patient (age 16) is transitioning to adult care. The transplant coordinator identifies that the patient has been increasingly managing their own medications and appointments but demonstrates significant 'transitional non-adherence'—missing doses during high-stress school periods. The psychosocial intervention MOST likely to improve long-term outcomes in this specific scenario is:

Documenting non-adherence and informing the adult program without further psychosocial intervention, as adherence responsibility shifts at age 18
Prescribing a simplified once-daily immunosuppression regimen to reduce the cognitive burden
Implementing a structured transition program that includes adolescent-specific health literacy training, self-advocacy skill development, and graduated autonomy with explicit bridging support during identified high-stress periods (Correct answer)
Returning primary medication management to the parents until the patient reaches age 18

Correct answer: Implementing a structured transition program that includes adolescent-specific health literacy training, self-advocacy skill development, and graduated autonomy with explicit bridging support during identified high-stress periods

Transitional non-adherence in adolescents is a well-documented, high-risk phenomenon. Returning control to parents is developmentally regressive and fails to build the autonomous health management skills needed for adult care. Structured transition programs that develop health literacy, self-advocacy, and graduated responsibility—while providing explicit support during high-stress periods—have the strongest evidence base for improving long-term adherence outcomes. Simplifying a regimen is a medical decision outside the coordinator's unilateral scope, and passive documentation without intervention represents a missed psychosocial care opportunity.

Question 70: A liver transplant recipient develops hypertension, hyperlipidemia, and new-onset diabetes 2 years post-transplant. These findings together are best described as:

Opportunistic infection sequelae
Chronic rejection
Calcineurin inhibitor nephrotoxicity
Post-transplant metabolic syndrome (Correct answer)

Correct answer: Post-transplant metabolic syndrome

The cluster of hypertension, dyslipidemia, and new-onset diabetes after transplant (NODAT) defines post-transplant metabolic syndrome, largely driven by immunosuppression.

Question 71: Standard post-transplant prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) protects against which two pathogens simultaneously?

Aspergillus and Candida
PJP and Toxoplasma gondii (Correct answer)
CMV and EBV
BK virus and HSV

Correct answer: PJP and Toxoplasma gondii

TMP-SMX provides dual prophylaxis against Pneumocystis jirovecii pneumonia (PJP) and Toxoplasma gondii, and also provides some urinary tract infection prophylaxis.

Question 72: A pre-transplant candidate has a BMI of 42 kg/m². How does this typically affect transplant listing decisions?

Only patients with BMI over 50 face any restrictions
Morbid obesity is associated with increased perioperative risk and many centers require weight loss before listing (Correct answer)
The patient should receive an immediate living donor transplant to avoid waitlist time
BMI has no impact on transplant outcomes or listing criteria

Correct answer: Morbid obesity is associated with increased perioperative risk and many centers require weight loss before listing

Morbid obesity (BMI ≥40) significantly increases surgical risk and many transplant centers require weight reduction to a safer BMI threshold before listing.

Question 73: A coordinator is managing a multi-organ listing (kidney-pancreas). Under allocation policy, how are multi-organ candidates prioritized compared to single-organ candidates?

Multi-organ candidates are ranked separately on an exclusive multi-organ list only
Multi-organ candidates receive lower priority to preserve single organs for waiting candidates
Multi-organ candidates receive priority over single-organ kidney candidates for the paired organ (Correct answer)
Priority is determined solely by time on the kidney waitlist regardless of additional organ need

Correct answer: Multi-organ candidates receive priority over single-organ kidney candidates for the paired organ

OPTN policy gives simultaneous pancreas-kidney candidates priority over kidney-alone candidates to ensure the pancreas is not wasted if the kidney portion is declined.

Question 74: Which ethical principle most directly supports offering a transplant to an older candidate with lower expected graft survival over a younger candidate with higher expected survival?

Justice (Correct answer)
Autonomy
Beneficence
Non-maleficence

Correct answer: Justice

Justice demands fair access to transplantation regardless of age, balancing utility with equitable distribution.

Question 75: A study comparing tacrolimus to cyclosporine for prevention of acute rejection reports a p-value of 0.03. What is the correct interpretation of this p-value?

There is a 3% absolute reduction in rejection risk with tacrolimus
The study has 97% statistical power to detect this difference
The result is clinically significant and should immediately change practice
There is a 3% probability of observing results this extreme (or more extreme) if there were truly no difference between the drugs (Correct answer)

Correct answer: There is a 3% probability of observing results this extreme (or more extreme) if there were truly no difference between the drugs

A p-value of 0.03 means: if the null hypothesis (no difference between drugs) were true, there would be only a 3% chance of observing results this extreme by chance alone. A p-value does not measure effect size, clinical importance, or the probability that the null hypothesis is true. Statistical significance (p<0.05) does not automatically equal clinical significance.

Question 76: A procurement coordinator is managing a multi-organ donor. The pancreas team requests the aorta be flushed with cold UW solution via an aortic cannula, while the liver team insists on a portal vein flush with Custodiol HTK solution. Which statement BEST describes the evidence-based approach to this conflict?

The liver team's preference takes precedence because hepatic graft function is more sensitive to preservation solution mismatch
A dual-flush technique using aortic UW and portal HTK is acceptable and used in some centers, with outcomes data supporting either approach for the pancreas (Correct answer)
HTK must be used for both flushes because its low-viscosity properties ensure uniform pancreatic distribution
UW solution is contraindicated via the portal vein due to its high potassium content causing splanchnic vasoconstriction

Correct answer: A dual-flush technique using aortic UW and portal HTK is acceptable and used in some centers, with outcomes data supporting either approach for the pancreas

In multi-organ procurement, a dual-flush approach (aortic UW for abdominal organs, portal HTK for the liver) is practiced in many centers, and comparative studies have not demonstrated clear superiority of one approach for the pancreas — both UW and HTK are used with acceptable outcomes. HTK's low viscosity is an advantage but does not mandate exclusive use. UW solution's high potassium does not cause clinically significant vasoconstriction at flush volumes used in situ. There is no hierarchical rule giving the liver team precedence; coordination between teams is standard.

Question 77: A transplant center lists a patient with advanced hepatocellular carcinoma who meets Milan criteria on initial imaging. Eighteen months later, restaging imaging shows the patient has exceeded Milan criteria, but the listing physician documents a 'downstaging response' to locoregional therapy and requests MELD exception points be maintained. The coordinator reviews the imaging report and notes the radiologist's read does not support downstaging. Under OPTN policy, what is the coordinator's primary obligation?

Defer entirely to the listing physician's clinical judgment, as the coordinator's role is administrative and the physician bears full medical and legal responsibility for exception point requests
Proactively contact the regional review board to report the discrepancy, bypassing the listing physician to ensure regulatory compliance
Ensure the accurate radiology report and the discrepancy with the physician's documentation are transparently reflected in the UNOS exception request submission, and escalate internally if the submission appears to misrepresent the patient's status (Correct answer)
Remove the patient from the waiting list immediately pending clarification, as maintaining a listing with inaccurate exception criteria constitutes fraud under federal law

Correct answer: Ensure the accurate radiology report and the discrepancy with the physician's documentation are transparently reflected in the UNOS exception request submission, and escalate internally if the submission appears to misrepresent the patient's status

OPTN policy requires that exception point requests accurately reflect the patient's clinical status. The transplant coordinator, as the individual who often compiles and submits this documentation, shares responsibility for the accuracy of UNOS submissions. When a discrepancy exists between imaging and physician documentation, the coordinator must ensure accurate data is included in the submission and escalate internally through appropriate channels (e.g., transplant program leadership, compliance). Bypassing the physician directly to the review board is premature without internal escalation. Unilaterally removing the patient is outside the coordinator's authority. Deferring completely ignores the coordinator's professional and regulatory accountability.

Question 78: A simultaneous pancreas-kidney (SPK) transplant recipient on post-operative day 5 has an amylase of 2,200 U/L and lipase of 3,800 U/L with no abdominal pain. Pancreas graft bladder drainage is intact. Urine amylase is 18,000 U/L. Which of the following is the MOST accurate interpretation?

The elevated enzymes confirm graft pancreatitis requiring surgical exploration
Urine amylase below 20,000 U/L indicates pancreatic exocrine insufficiency and graft failure
This pattern is diagnostic of acute pancreatic rejection and warrants pulse steroids immediately
Elevated serum amylase and lipase are expected post-SPK with bladder drainage and do not indicate rejection alone (Correct answer)

Correct answer: Elevated serum amylase and lipase are expected post-SPK with bladder drainage and do not indicate rejection alone

In bladder-drained SPK recipients, serum amylase and lipase are frequently elevated in the early post-operative period due to exocrine secretions drained into the bladder and absorbed systemically. This alone is not diagnostic of rejection. Monitoring urine amylase (which reflects exocrine output into the bladder) is more useful — a falling urine amylase trend (not the absolute value at one time point) raises concern for rejection. Acute rejection diagnosis requires biopsy or clinical correlation beyond enzyme levels alone.

Question 79: A potential donor has a positive nucleic acid test (NAT) for HCV. The intended kidney recipient has been waitlisted for 6 years and faces continued deteriorating health on dialysis. After thorough discussion, the recipient provides informed consent to accept the organ. Which statement is correct?

With recipient informed consent and the availability of curative direct-acting antiviral (DAA) therapy, transplanting an HCV-NAT-positive organ into an HCV-negative recipient is an accepted and policy-compliant practice (Correct answer)
Only centers with a specific HCV waiver from CMS may perform such transplants
The transplant must be reported to UNOS as a mandatory protocol violation
Acceptance is prohibited; HCV-positive organs may only be transplanted into HCV-positive recipients

Correct answer: With recipient informed consent and the availability of curative direct-acting antiviral (DAA) therapy, transplanting an HCV-NAT-positive organ into an HCV-negative recipient is an accepted and policy-compliant practice

The advent of highly effective pan-genotypic DAA therapies (>95% cure rates) has transformed HCV-positive donor organs from an absolute contraindication to an accepted practice. UNOS policy permits transplanting HCV-viremic organs into HCV-negative recipients with informed consent, significantly expanding the donor pool. Post-transplant DAA treatment reliably clears the infection.

Question 80: A heart transplant coordinator is reviewing the immunosuppression of a patient who was converted from mycophenolate mofetil (MMF) to enteric-coated mycophenolate sodium (EC-MPS) due to GI complaints. The physician notes that the patient's MPA AUC appears lower than expected despite equivalent labeled dosing. Which pharmacokinetic factor most likely explains this discrepancy?

EC-MPS is more tightly bound to albumin, reducing free MPA available for IMPDH inhibition
EC-MPS delays absorption to the small intestine, reducing enterohepatic recirculation of MPA and lowering the secondary AUC peak (Correct answer)
EC-MPS undergoes greater first-pass metabolism by intestinal glucuronidases than MMF
EC-MPS requires alkaline pH for dissolution; proton pump inhibitor co-administration prevents its release entirely

Correct answer: EC-MPS delays absorption to the small intestine, reducing enterohepatic recirculation of MPA and lowering the secondary AUC peak

MPA undergoes significant enterohepatic recirculation: MPA-glucuronide (MPAG) excreted in bile is deconjugated by intestinal bacteria and reabsorbed as MPA, producing a characteristic secondary peak in the pharmacokinetic curve approximately 6–12 hours post-dose. EC-MPS releases MPA more distally in the GI tract than MMF, which shifts the site of absorption and can blunt or alter the enterohepatic recirculation contribution to total AUC. The labeled doses of MMF 1g and EC-MPS 720mg are considered bioequivalent on average, but individual pharmacokinetic variability—particularly in the secondary peak—can result in lower measured MPA AUC in some patients switched to EC-MPS.

Question 81: A coordinator discovers that a colleague falsified a recipient's lab values to improve their organ allocation score. What is the most appropriate immediate action?

Alert the transplant surgeon only, as they are responsible for the patient
Confront the colleague privately before taking further action
Report the incident to institutional leadership and the OPO compliance department (Correct answer)
Document the observation and wait for corroborating evidence

Correct answer: Report the incident to institutional leadership and the OPO compliance department

Falsifying allocation data is a serious ethical and legal violation requiring immediate reporting to institutional and OPO compliance channels.

Question 82: A deceased-donor kidney is being evaluated for transplant suitability. The donor is a 58-year-old with hypertension and a terminal creatinine of 3.4 mg/dL. Procurement biopsy shows 32% global glomerulosclerosis, moderate arteriolar hyalinosis, and mild interstitial fibrosis. Under which scenario would dual kidney transplantation (both kidneys to one recipient) most appropriately be considered over single kidney transplantation or discard?

Expanded Criteria Donor (ECD) status alone, regardless of biopsy findings
Kidney Donor Profile Index (KDPI) >85% with an estimated post-transplant eGFR of >45 mL/min per kidney when combined (Correct answer)
Recipient body surface area >2.0 m² with a predicted high metabolic demand
Cold ischemia time exceeding 24 hours with KDPI <85%

Correct answer: Kidney Donor Profile Index (KDPI) >85% with an estimated post-transplant eGFR of >45 mL/min per kidney when combined

Dual kidney transplantation is most appropriate when individual kidney nephron mass is insufficient to support adequate renal function in a single recipient but when combined function is projected to be adequate (typically estimated post-transplant eGFR ≥40–45 mL/min per kidney as a pair). KDPI >85% combined with biopsy findings of >20% global glomerulosclerosis and moderate chronic changes (as seen here) is the prototypical indication — placing both kidneys in one recipient maximizes utilization of a marginal organ pair. ECD status alone is insufficient justification; cold ischemia time is a consideration for procurement timing but not the primary dual-transplant trigger; and recipient body surface area is not a validated criterion for dual transplant decisions.

Question 83: A 58-year-old male with end-stage renal disease is undergoing evaluation for kidney transplantation. Which of the following is considered an absolute contraindication to proceeding with the transplant?

A body mass index (BMI) of 38 kg/m²
A history of well-controlled hypertension
A previous history of medication non-adherence
An active, untreated malignancy (Correct answer)

Correct answer: An active, untreated malignancy

An active, untreated malignancy is an absolute contraindication for kidney transplantation. The required immunosuppressive therapy following transplant could accelerate cancer recurrence or metastasis. Other absolute contraindications include severe cardiac or pulmonary disease making surgery intolerable, active infection, and uncontrolled psychiatric disease. Morbid obesity, hypertension, and a history of non-adherence are typically considered relative contraindications that require management and careful consideration.

Question 84: Which of the following laboratory values is a component of the Model for End-Stage Liver Disease-Sodium (MELD-Na) score used for adult liver allocation?

Prothrombin Time (PT)
Serum Albumin
Aspartate aminotransferase (AST)
Total Bilirubin (Correct answer)

Correct answer: Total Bilirubin

The MELD-Na score is calculated using four variables: total bilirubin, serum creatinine, International Normalized Ratio (INR), and serum sodium. While serum albumin and PT are important measures of liver function, they are not direct components of the current MELD-Na formula used for organ allocation (INR is the standardized value derived from PT).

Question 85: A patient's spouse asks how they can help monitor for transplant complications at home. Which tool is most commonly recommended?

Monthly urine culture collection
Weekly chest X-ray at an urgent care clinic
Biweekly echocardiogram at home
Daily temperature, blood pressure, and weight log (Correct answer)

Correct answer: Daily temperature, blood pressure, and weight log

Daily vital signs and weight monitoring allows early detection of infection, rejection, and fluid retention at home.

Question 86: A transplant coordinator is reviewing a candidate for heart transplant who has a calculated Panel Reactive Antibody (cPRA) of 94%. The patient has donor-specific antibodies (DSAs) against HLA-DQ7 and HLA-B44. Which of the following statements most accurately reflects how this affects transplant candidacy and allocation?

The patient should be removed from the waitlist until plasmapheresis reduces the cPRA below 80%, as no allocation advantage exists for highly sensitized patients above this threshold
A cPRA of 94% is an absolute contraindication to transplant and the patient must undergo desensitization before being listed
A cPRA of 94% means approximately 94% of the donor pool would be incompatible, qualifying the patient for additional UNOS allocation points and requiring a prospective crossmatch or virtual crossmatch prior to offer acceptance (Correct answer)
DSAs against HLA-DQ loci are clinically irrelevant because DQ antigens are not expressed on cardiac endothelium

Correct answer: A cPRA of 94% means approximately 94% of the donor pool would be incompatible, qualifying the patient for additional UNOS allocation points and requiring a prospective crossmatch or virtual crossmatch prior to offer acceptance

A cPRA of 94% indicates that the patient has antibodies against 94% of the general donor pool, making compatible donors rare but not eliminating candidacy. UNOS provides allocation priority for highly sensitized patients to improve their access to compatible organs. A prospective or virtual crossmatch is required before accepting an offer to prevent hyperacute rejection. High cPRA is not an absolute contraindication, and desensitization is one option but not a mandatory prerequisite for listing. HLA-DQ DSAs are clinically significant in all solid organ transplants.

Question 87: A kidney transplant coordinator is conducting a post-transplant psychosocial follow-up at 6 months with a recipient who emigrated from a country where expressing emotional distress to medical professionals is culturally stigmatized. He rates all standardized distress measures (PHQ-9, FACT-G) in low-risk ranges but the coordinator observes somatic complaints, social withdrawal, and a statement that 'I am fine, I just have no energy for anything.' Which approach BEST addresses the limitations of standardized screening in this context?

Accept the standardized scores as valid; Western-validated instruments are culturally neutral by design
Re-administer the PHQ-9 with a professional interpreter present, as translation error likely accounts for discordance
Supplement screening tool results with culturally-informed clinical interview techniques, attention to somatic idioms of distress, and collateral history from family when appropriate (Correct answer)
Refer immediately to psychiatry because somatic complaints with low distress scores indicate masked psychosis

Correct answer: Supplement screening tool results with culturally-informed clinical interview techniques, attention to somatic idioms of distress, and collateral history from family when appropriate

Standardized tools like the PHQ-9 were largely validated in Western, English-speaking populations and may underdetect distress in cultures where psychological distress is expressed somatically or where disclosure to authority figures is stigmatized. The culturally competent coordinator recognizes this limitation and supplements with open-ended, culturally-informed clinical interviewing, awareness of somatic idioms of distress, and collateral history. Translation alone does not resolve cultural response bias in self-report measures. Somatic complaints with low standardized scores do not indicate psychosis.

Question 88: A transplant coordinator is reviewing a death record for a potential deceased donor. The donor died after a witnessed cardiac arrest and was resuscitated but later declared brain dead. The down-time before ROSC was 38 minutes. The OPO procurement coordinator requests the liver for a recipient with MELD 32. Which regulatory framework MOST governs the transplant program's decision to accept or decline this offer?

OPTN policy requiring mandatory acceptance of all organs offered to Status 1A and high-MELD candidates regardless of donor risk indices
The transplant program's own medical criteria and OPTN variance policies, within the bounds of non-discrimination rules (Correct answer)
CMS Conditions of Participation §482.98 mandating refusal of organs with anticipated primary non-function rates above 30%
UNOS regional review board pre-authorization, which must approve acceptance of any DCD or extended-criteria donor organ

Correct answer: The transplant program's own medical criteria and OPTN variance policies, within the bounds of non-discrimination rules

Organ acceptance decisions are primarily governed by each transplant program's own medically established criteria, developed within the framework of OPTN policies. Programs have clinical discretion to decline organs based on donor risk factors, including prolonged warm ischemia time, provided these decisions are not discriminatory (e.g., based on recipient's HIV status, disability, or other protected characteristics). There is no CMS mandate setting a specific PNF threshold for refusal, no rule mandating acceptance for high-MELD patients, and no regional pre-authorization process for ECD or DCD acceptance.

Question 89: A 45-year-old female is being evaluated for a lung transplant. Her infectious disease screening comes back positive for latent tuberculosis infection (LTBI) via a PPD skin test, with a negative chest X-ray. What is the most appropriate next step?

Immediately list her for transplant as she has no active disease.
Initiate treatment for LTBI before or after transplantation. (Correct answer)
Repeat the PPD test in three months to confirm the result.
Permanently disqualify her from transplant consideration.

Correct answer: Initiate treatment for LTBI before or after transplantation.

Active infection is an absolute contraindication, but latent infection is not. For candidates with LTBI, the standard of care is to consider prophylactic therapy (e.g., with isoniazid) to prevent reactivation of the disease after post-transplant immunosuppression is initiated. The decision on the timing of treatment (before or after transplant) depends on the individual's clinical situation. Disqualification is not necessary, and waiting to repeat the test would cause an unnecessary delay.

Question 90: A liver transplant coordinator is reviewing the infection risk of a donor who died of bacterial meningitis caused by Neisseria meningitidis confirmed on CSF culture. The donor received 18 hours of appropriate IV ceftriaxone before procurement. Which statement BEST reflects current guidance on organ utilization from this donor?

Organs may be used with recipient prophylaxis matching the donor's documented sensitivities, given adequate pre-procurement antibiotic exposure and documented clinical response (Correct answer)
Only kidneys should be used, as hepatic sinusoids filter circulating bacteria and the liver itself is considered a high-risk organ in bacteremic donors
Organs should be declined entirely; bacteremic meningitis donors carry unacceptable transmitted infection risk regardless of antibiotic duration
Organs are safe to use without any special recipient prophylaxis because 18 hours of ceftriaxone is sufficient to sterilize all donor tissues

Correct answer: Organs may be used with recipient prophylaxis matching the donor's documented sensitivities, given adequate pre-procurement antibiotic exposure and documented clinical response

Current UNOS/ASTS guidance supports use of organs from donors with treated bacterial meningitis, including N. meningitidis, when there has been an adequate response to appropriate antibiotics prior to procurement. Recipients should receive prophylactic antibiotics guided by the donor's organism and sensitivities. The key factors are documented clinical improvement, appropriate therapy, and pathogen identification — not blanket exclusion or unconditional acceptance without recipient coverage.

Question 91: A heart transplant recipient is 18 hours post-op with a cardiac index of 1.7 L/min/m², SVR of 2,100 dynes·sec/cm⁻⁵, CVP of 22 mmHg, and pulmonary capillary wedge pressure of 28 mmHg. The patient received a donor heart with a 6-hour ischemic time. Which hemodynamic intervention is MOST appropriate?

Administer IV fluid bolus to augment preload
Start norepinephrine to increase SVR and MAP
Initiate inhaled nitric oxide to reduce right ventricular afterload (Correct answer)
Perform immediate endomyocardial biopsy to rule out hyperacute rejection

Correct answer: Initiate inhaled nitric oxide to reduce right ventricular afterload

This presentation — low cardiac index with elevated filling pressures, high SVR, and prolonged ischemic time — is consistent with primary graft dysfunction (PGD) with right heart failure secondary to elevated pulmonary vascular resistance. The denervated donor heart is vulnerable to a recipient's pre-existing elevated PVR. Inhaled nitric oxide selectively reduces pulmonary vascular resistance, decreasing RV afterload and improving cardiac output without systemic hypotension. A fluid bolus would worsen the already elevated filling pressures. Norepinephrine would increase SVR and further strain the RV. Biopsy is not indicated emergently when the hemodynamic picture is explained by PGD and ischemia-reperfusion.

Question 92: A 52-year-old prospective living kidney donor is found to have a microalbuminuria of 35 mg/g creatinine on two separate 24-hour urine collections, with normal GFR and blood pressure. Which of the following best characterizes the significance of this finding in the donor evaluation?

Any confirmed microalbuminuria is an absolute contraindication per KDIGO donor selection guidelines
Microalbuminuria is an independent risk marker for progressive renal disease and should prompt further evaluation; donation may still proceed after individualized risk counseling (Correct answer)
Microalbuminuria below 150 mg/g is within acceptable range for living donation and requires no further workup
Microalbuminuria is only clinically significant if accompanied by hypertension or diabetes; isolated findings can be disregarded

Correct answer: Microalbuminuria is an independent risk marker for progressive renal disease and should prompt further evaluation; donation may still proceed after individualized risk counseling

Microalbuminuria (30–300 mg/g creatinine) is a recognized early marker of glomerular dysfunction and is associated with elevated long-term risk of CKD progression and cardiovascular disease. KDIGO living donor guidelines classify this as a relative contraindication requiring careful individualized risk assessment — not an absolute disqualification. The evaluating team must consider all other risk factors collectively and engage in detailed counseling about the compounded post-donation risk. Dismissing isolated microalbuminuria without further workup is inappropriate, as it may reflect underlying subclinical renal pathology.

Question 93: A renal transplant candidate with a history of transitional cell carcinoma of the bladder (T1, high-grade, treated with TURBT and BCG) completed treatment 18 months ago with no evidence of recurrence on most recent surveillance cystoscopy. The coordinator reviews the UNOS waiting period guidelines. What is the MOST appropriate next step?

Deny listing permanently because transitional cell carcinoma of the bladder is an absolute contraindication to transplant
List the patient immediately because high-grade T1 bladder cancer treated with intravesical therapy requires no waiting period
Require a 5-year disease-free waiting period before listing, as all high-grade non-muscle-invasive bladder cancers mandate this interval
Consult urology and oncology to determine recurrence risk; UNOS recommends individualized waiting periods for high-grade T1 urothelial carcinoma, often 2 years minimum (Correct answer)

Correct answer: Consult urology and oncology to determine recurrence risk; UNOS recommends individualized waiting periods for high-grade T1 urothelial carcinoma, often 2 years minimum

UNOS/OPTN and ASTS guidelines do not mandate a single universal waiting period for all bladder cancers. High-grade T1 urothelial carcinoma has significant recurrence and progression risk, but with complete resection and BCG response, individualized evaluation is recommended. Most transplant centers apply a minimum 2-year disease-free interval for high-grade non-muscle-invasive bladder cancer, with some centers extending to 5 years given progression risk to muscle-invasive disease. The key principle is individualized oncologic risk assessment in collaboration with urology and oncology — not automatic denial and not immediate listing. Permanent exclusion is not warranted for T1 disease.

Question 94: Under the OPTN 'Share 35' liver allocation policy, which of the following most accurately describes the allocation sequence when a donor liver becomes available and a local candidate has a MELD score of 38?

The organ is offered nationally to all MELD ≥35 candidates simultaneously before any local candidates are considered
The MELD 38 local candidate receives first priority because geographic proximity always supersedes MELD thresholds in liver allocation
Local Status 1A and 1B candidates are offered the organ first; then regional candidates with MELD ≥35 are offered the organ before local candidates with MELD <35 (Correct answer)
The organ is offered to regional candidates with MELD ≥35 before all local candidates, including Status 1A and 1B acute liver failure patients

Correct answer: Local Status 1A and 1B candidates are offered the organ first; then regional candidates with MELD ≥35 are offered the organ before local candidates with MELD <35

Share 35 (implemented 2013) requires that livers be offered regionally to candidates with MELD ≥35 before local candidates with MELD <35 — but it does not override the absolute highest-priority status designations. Local Status 1A (acute liver failure, ICU-level) and Status 1B (pediatric acute/chronic) candidates retain first priority above regional Share 35 offers. The local MELD 38 candidate would receive consideration after regional MELD ≥35 candidates take their queue position, unless that local candidate is also Status 1A/1B.

Question 95: A 58-year-old patient with hepatocellular carcinoma (HCC) within Milan criteria has been on the liver transplant waitlist for 14 months. His most recent AFP is 320 ng/mL and imaging shows stable disease. Under current UNOS policy, which factor would trigger automatic removal from the waitlist?

Tumor progression outside Milan criteria confirmed on restaging imaging
AFP rising above 500 ng/mL on two consecutive measurements 3 months apart
AFP exceeding 1,000 ng/mL at any single measurement regardless of imaging (Correct answer)
Total tumor volume exceeding 115 cc regardless of individual lesion size

Correct answer: AFP exceeding 1,000 ng/mL at any single measurement regardless of imaging

Under UNOS/OPTN policy, an AFP level exceeding 1,000 ng/mL at any single measurement is grounds for automatic delisting from the liver transplant waitlist, regardless of what restaging imaging shows, because it signals a high likelihood of metastatic or aggressive disease that would result in poor post-transplant outcomes. Tumor progression outside Milan criteria on imaging is also grounds for delisting, but AFP >1,000 ng/mL alone triggers automatic removal without requiring imaging confirmation.

Question 96: During evaluation of a donation after circulatory death (DCD) Category III (Maastricht) pancreas, the procurement surgeon notes warm ischemia time of 28 minutes. Which factor MOST critically determines whether this pancreas should be accepted for simultaneous pancreas-kidney (SPK) transplant?

Recipient panel reactive antibody (PRA) level below 20% to minimize rejection risk with the marginal organ
Cold ischemia time remaining budget after transport, with a target total ischemia under 12 hours
Absolute contraindication — DCD pancreata are never suitable for SPK due to exocrine dysfunction risk
Donor BMI below 30 kg/m² and absence of significant peripancreatic fat necrosis on inspection (Correct answer)

Correct answer: Donor BMI below 30 kg/m² and absence of significant peripancreatic fat necrosis on inspection

DCD pancreas transplantation is performed at select high-volume centers. With a 28-minute warm ischemia time (within the generally accepted ≤30-minute threshold), the key procurement-side determinants are donor BMI (<30 preferred), and direct visual inspection for fat necrosis or edema — signs of ischemic pancreatitis that preclude use. DCD pancreata are NOT absolutely contraindicated; outcomes at experienced centers are comparable to DBD when selection criteria are met. Recipient PRA and cold ischemia are relevant but secondary to the organ quality inspection at procurement.

Question 97: A potential living kidney donor expresses significant fear and anxiety about the surgery during the psychosocial evaluation. However, they insist on proceeding because they feel an immense obligation to their sibling, the recipient. Which of the following is the MOST appropriate next step for the transplant coordinator?

Recommend the donor and recipient attend joint counseling to resolve the issue.
Engage the Independent Living Donor Advocate (ILDA) to meet with the donor to explore their feelings and ensure their decision is voluntary. (Correct answer)
Inform the recipient's team that the donor is ambivalent and suggest pausing the recipient's workup.
Document the donor's anxiety and proceed with the evaluation as the donor has consented.

Correct answer: Engage the Independent Living Donor Advocate (ILDA) to meet with the donor to explore their feelings and ensure their decision is voluntary.

The primary responsibility in the living donor assessment is to protect the potential donor's autonomy and ensure their decision is free from coercion or undue pressure. The Independent Living Donor Advocate (ILDA) is a crucial team member whose role is to promote the donor's best interests and advocate for their rights. When a donor expresses significant fear but feels a strong obligation, it's a critical point to ensure voluntariness. The ILDA is specifically trained to explore these feelings in a confidential setting, separate from the recipient's team, to ensure the donor's decision is truly their own.

Question 98: Which of the following statements is true regarding a transplant candidate's ability to be listed at multiple transplant centers?

It is prohibited by OPTN policy to prevent an unfair advantage.
OPTN policy allows candidates to be listed at more than one transplant center, and they may transfer their primary accrued waiting time between centers. (Correct answer)
A candidate's accrued waiting time from each center is added together to create a longer total waiting time.
Candidates can only be listed at multiple centers if they are in different UNOS regions.

Correct answer: OPTN policy allows candidates to be listed at more than one transplant center, and they may transfer their primary accrued waiting time between centers.

OPTN policy permits multiple listing, allowing candidates to be registered on the waitlist at two or more transplant centers. A candidate can also request to transfer their primary waiting time from one center to another, but they cannot combine or add waiting times from different listings.

Question 99: A liver transplant recipient is 18 hours post-reperfusion. Labs show AST 3,200 U/L, ALT 2,800 U/L, PT 28 seconds, and bile output from the T-tube is 5 mL over 12 hours. Doppler ultrasound demonstrates normal hepatic artery waveforms bilaterally. What is the MOST appropriate next diagnostic step?

Repeat Doppler in 6 hours, as early waveforms may not reflect true perfusion
Urgent re-exploration to assess portal vein flow and biliary anastomosis integrity
Liver biopsy to differentiate primary non-function from ischemia-reperfusion injury
CT angiography of the hepatic vasculature to rule out arterial steal syndrome (Correct answer)

Correct answer: CT angiography of the hepatic vasculature to rule out arterial steal syndrome

In the setting of elevated transaminases, poor bile output, and normal hepatic artery Doppler at the hilum, splenic artery steal syndrome must be excluded. The splenic artery can siphon flow from the hepatic artery despite normal proximal waveforms; CT angiography or selective angiography will detect the steal and guide embolization. Biopsy is premature before vascular causes are excluded. Repeating Doppler is inappropriate when clinical indicators suggest a time-sensitive problem. Re-exploration without first identifying the etiology is not the standard diagnostic algorithm at this stage.

Question 100: During a pre-transplant education session for a heart transplant candidate, the coordinator is teaching about post-transplant infection prophylaxis. The patient asks why they will need lifelong low-dose trimethoprim-sulfamethoxazole (TMP-SMX) rather than stopping it after 6–12 months like they read online. What is the most accurate explanation the coordinator should provide?

TMP-SMX is continued lifelong only in patients who have had a prior Pneumocystis jirovecii pneumonia (PJP) episode
Lifelong TMP-SMX is universally recommended for all heart transplant recipients regardless of center protocol
Some centers continue TMP-SMX indefinitely due to its additional benefit in preventing Toxoplasma gondii reactivation, particularly in donor-positive/recipient-negative serologic mismatches (Correct answer)
The online resources are correct; TMP-SMX is typically discontinued after 12 months in stable patients

Correct answer: Some centers continue TMP-SMX indefinitely due to its additional benefit in preventing Toxoplasma gondii reactivation, particularly in donor-positive/recipient-negative serologic mismatches

TMP-SMX prophylaxis duration varies by center protocol, but heart transplant recipients carry unique risk for Toxoplasma gondii if the donor was seropositive and the recipient seronegative (D+/R−). In these cases, many centers continue TMP-SMX indefinitely because it provides dual coverage for both PJP and toxoplasmosis. This is a nuanced point that distinguishes heart transplant management from other solid organ transplants and reflects why online generalizations can be misleading.

Question 101: A transplant coordinator is responsible for submitting follow-up data on a recipient who is now one-year post-kidney transplant. Which OPTN-mandated form must be completed to report the recipient's current clinical status, graft function, and any significant complications?

Transplant Recipient Follow-up (TRF) Form (Correct answer)
Living Donor Follow-up (LDF) Form
Transplant Candidate Registration (TCR) Form
Deceased Donor Registration (DDR) Form

Correct answer: Transplant Recipient Follow-up (TRF) Form

The Organ Procurement and Transplantation Network (OPTN) requires transplant centers to submit detailed follow-up data on all recipients at specific intervals (e.g., six months, one year, and annually thereafter). The Transplant Recipient Follow-up (TRF) form is the official document used for this purpose to track graft status, patient status, immunosuppression, and other clinical data.

Question 102: A kidney transplant recipient 8 years post-transplant is referred for evaluation of new hypertension that is refractory to three antihypertensive agents including a calcium channel blocker, an ACE inhibitor, and a thiazide diuretic. His tacrolimus trough is 6.2 ng/mL. Laboratory shows mild hypokalemia (3.2 mEq/L), metabolic alkalosis, and elevated aldosterone-to-renin ratio of 38 (normal <30). CT scan shows a 1.8 cm left adrenal adenoma. The transplant coordinator should flag this as:

Primary hyperaldosteronism requiring AVS (adrenal vein sampling) to confirm lateralization before consideration of laparoscopic adrenalectomy, with appropriate pre-operative alpha-blockade
Primary hyperaldosteronism (Conn's syndrome); the ACE inhibitor should be discontinued immediately as it is contraindicated in primary aldosteronism and may precipitate acute rejection
Primary hyperaldosteronism; the appropriate next step is adrenal vein sampling to confirm lateralization, with laparoscopic adrenalectomy for confirmed unilateral disease — and the team must anticipate potential immunosuppression pharmacokinetic changes post-operatively (Correct answer)
A calcineurin inhibitor-mediated pseudohyperaldosteronism; the findings are expected in long-term tacrolimus recipients and the adrenal adenoma is likely an incidental non-functioning adenoma

Correct answer: Primary hyperaldosteronism; the appropriate next step is adrenal vein sampling to confirm lateralization, with laparoscopic adrenalectomy for confirmed unilateral disease — and the team must anticipate potential immunosuppression pharmacokinetic changes post-operatively

Primary hyperaldosteronism (PA) is the most common cause of secondary hypertension and is underdiagnosed in transplant recipients. The ARR >30, hypokalemia, metabolic alkalosis, and adrenal adenoma are classic. AVS is required to confirm lateralization (CT misses ~40% of bilateral disease). Laparoscopic adrenalectomy is curative for unilateral disease. Critically, post-operative changes in cortisol, aldosterone, and fluid shifts can alter tacrolimus pharmacokinetics — the transplant team must plan for more frequent trough monitoring and potential dose adjustments. ACE inhibitors are not contraindicated in PA; they are less effective but safe. CNI-induced hypertension does not cause true hyperaldosteronism. Option C is incomplete because it omits the transplant-specific pharmacokinetic consideration.

Question 103: A listed transplant recipient is found to have relapsed to illicit drug use. According to UNOS policy and standard transplant practice, what is the most appropriate immediate action?

Permanently delist the patient without further evaluation
Proceed with transplant if an organ becomes available immediately
Place the patient on hold status and refer to substance use treatment (Correct answer)
Notify law enforcement about the substance use

Correct answer: Place the patient on hold status and refer to substance use treatment

UNOS policy requires that patients be placed on hold and referred for appropriate substance use treatment; permanent delisting decisions follow a structured multidisciplinary review.

Question 104: During evaluation of a potential living liver donor, volumetric CT reveals a left lobe volume of 38% of the total estimated liver volume (TELV) with 12% hepatic steatosis. The intended recipient has a MELD score of 28 and weighs 90 kg. Which factor is the MOST critical determinant of whether this donation plan is safe to proceed?

The graft-to-recipient weight ratio (GRWR), which must typically exceed 0.8% to avoid small-for-size syndrome (Correct answer)
The degree of steatosis, which absolutely contraindicates donation if greater than 10%
The donor's remnant liver volume, which must be at least 20% for safe donor hepatectomy
The recipient's MELD score, which is too high for a left lobe graft regardless of other factors

Correct answer: The graft-to-recipient weight ratio (GRWR), which must typically exceed 0.8% to avoid small-for-size syndrome

In living donor liver transplantation, the graft-to-recipient weight ratio (GRWR) is the critical determinant of small-for-size syndrome (SFSS) risk. A GRWR <0.8% significantly increases the risk of SFSS, which causes primary non-function or dysfunction in the setting of portal hyperperfusion relative to graft mass. A 90 kg recipient with a left lobe must have the GRWR calculated; a left lobe at 38% TELV may not provide sufficient mass. Steatosis >30% (not 10%) is a contraindication. MELD 28 increases recipient urgency but doesn't absolutely preclude left lobe. Donor remnant safety threshold is ≥30% (not 20%) in most programs.

Question 105: A kidney transplant recipient 9 years post-transplant is found to have a 3.2 cm solid renal mass in the native (non-transplant) kidney on routine surveillance imaging. He has a history of end-stage renal disease from ADPKD. His current immunosuppression is tacrolimus 3 mg BID, mycophenolate mofetil 750 mg BID, and prednisone 5 mg/day. Which management consideration is MOST specific to his transplant status?

Immediately discontinue all immunosuppression to allow immune clearance of the malignancy
Native nephrectomy is contraindicated because it may precipitate allograft rejection
Consider converting to an mTOR inhibitor-based regimen given mTOR inhibitors' anti-neoplastic properties in post-transplant patients (Correct answer)
Pursue active surveillance only, as surgical risk outweighs benefit in immunocompromised patients

Correct answer: Consider converting to an mTOR inhibitor-based regimen given mTOR inhibitors' anti-neoplastic properties in post-transplant patients

Post-transplant patients on CNI-based regimens have a substantially elevated risk of de novo malignancies, and mTOR inhibitors (sirolimus, everolimus) have demonstrated anti-tumor properties by inhibiting the PI3K/Akt/mTOR pathway, which is relevant to renal cell carcinoma. Current guidelines suggest considering conversion to an mTOR inhibitor-containing regimen when post-transplant malignancy is diagnosed, balancing anti-rejection needs with anti-neoplastic benefit. Immediately stopping all immunosuppression risks acute and chronic rejection, is not standard practice, and does not reliably induce tumor clearance. Native nephrectomy is not contraindicated. Active surveillance alone for a 3.2 cm solid renal mass would not be standard of care.

Question 106: A transplant coordinator is counseling a patient about tacrolimus. Which instruction is most important regarding grapefruit consumption?

Grapefruit has no interaction with tacrolimus
Grapefruit juice can be consumed in moderation with dose adjustment
Grapefruit juice enhances renal clearance of tacrolimus
Grapefruit should be avoided as it inhibits CYP3A4 and can significantly increase tacrolimus levels (Correct answer)

Correct answer: Grapefruit should be avoided as it inhibits CYP3A4 and can significantly increase tacrolimus levels

Grapefruit inhibits intestinal CYP3A4 metabolism, leading to unpredictably elevated tacrolimus blood levels and toxicity risk.

Question 107: A transplant coordinator at a combined transplant and procurement program learns that a colleague has been systematically offering higher-quality organs to in-house recipients at their own center before offering them to appropriately ranked candidates at other centers, citing 'logistical efficiency.' No policy has been formally violated yet because the colleague exploits a narrow time window before UNOS match run obligations formally attach. The coordinator has no supervisory authority. What is the most ethically and professionally appropriate course of action?

Document the observed pattern in personal notes for future reference but take no immediate action, since no formal OPTN violation has occurred and acting prematurely could damage a colleague's career
Report the practice to UNOS/OPTN via the compliance hotline, as the behavior constitutes an emerging pattern of allocation manipulation even if no formal violation has technically occurred yet
Consult with the hospital's legal department only, as organ allocation irregularities are a legal matter outside the coordinator's professional scope to report independently
Raise the concern with the program's designated transplant physician and compliance officer first, and if no corrective action is taken, escalate to OPTN (Correct answer)

Correct answer: Raise the concern with the program's designated transplant physician and compliance officer first, and if no corrective action is taken, escalate to OPTN

OPTN policy and professional ethics require that allocation irregularities — including systematic patterns designed to circumvent allocation intent — be reported, even if the conduct exploits ambiguous timing windows. The appropriate escalation path is internal first (transplant physician and compliance officer), which preserves due process and allows the institution to self-correct before regulatory involvement. If internal escalation fails or is refused, OPTN reporting is mandatory. Going directly to UNOS without internal escalation bypasses institutional process; inaction is ethically untenable when a pattern of inequitable allocation is observed; and limiting the report to legal counsel ignores the coordinator's professional obligations under OPTN membership requirements.

Question 108: A heart transplant recipient on mycophenolate mofetil (MMF) calls to report profuse, watery diarrhea for 3 days. She has been self-managing with loperamide and herbal antidiarrheal teas. What is the MOST important education point to address first?

Advise her to switch to mycophenolate sodium (Myfortic) immediately, as it has an enteric coating that prevents GI side effects entirely
Instruct her to halve her MMF dose temporarily until diarrhea resolves, then resume the full dose when stool normalizes
Reassure her that MMF-related diarrhea is common and self-limited; advise her to continue loperamide and increase oral fluid intake
Explain that persistent diarrhea can alter MMF absorption and expose her to opportunistic infections like CMV colitis, and she must be evaluated promptly (Correct answer)

Correct answer: Explain that persistent diarrhea can alter MMF absorption and expose her to opportunistic infections like CMV colitis, and she must be evaluated promptly

Persistent diarrhea in a transplant recipient warrants urgent evaluation for several reasons: (1) it can impair MMF absorption, potentially causing sub-therapeutic immunosuppression; (2) diarrhea itself may be caused by CMV colitis, a serious opportunistic infection requiring antiviral therapy; (3) dehydration can precipitate calcineurin inhibitor nephrotoxicity. Self-medicating with herbal teas introduces unknown drug interactions. Patients should never self-adjust immunosuppression doses, and Myfortic reduces but does not eliminate GI side effects.

Question 109: A liver transplant candidate with alcohol-related cirrhosis has 8 months of documented sobriety (below many centers' 6-month minimum, but below others' 12-month threshold). The patient voluntarily enrolled in an intensive outpatient program, attends peer support meetings three times weekly, has strong family support, and psychosocial risk tools indicate low relapse probability. What is the most appropriate action for the transplant coordinator?

Advise the patient to return in 4 months to meet an absolute 12-month sobriety requirement before evaluation can proceed
Recommend mandatory residential rehabilitation prior to any listing consideration, regardless of outpatient program participation
Proceed with listing immediately, since validated relapse-risk instruments supersede sobriety duration requirements when scores are favorable
Document the comprehensive psychosocial assessment findings thoroughly and present them to the multidisciplinary team for an individualized listing decision (Correct answer)

Correct answer: Document the comprehensive psychosocial assessment findings thoroughly and present them to the multidisciplinary team for an individualized listing decision

The transplant coordinator's role is to document and present the full psychosocial picture — not to make the listing decision unilaterally. Sobriety duration is one factor among many (program participation, insight, support system, relapse risk tools), and listing decisions are individualized by the MDT. No universal 12-month requirement exists across all centers (A). Mandatory residential rehab is not automatically required when robust outpatient engagement is documented (C). Coordinators do not have authority to list a patient based on their own interpretation of risk scores (D).

Question 110: A liver transplant recipient develops biliary anastomotic stricture 6 months post-transplant. Which intervention is typically first-line?

Surgical revision of the anastomosis
Retransplantation
Increased immunosuppression
Endoscopic retrograde cholangiopancreatography (ERCP) with dilation and stenting (Correct answer)

Correct answer: Endoscopic retrograde cholangiopancreatography (ERCP) with dilation and stenting

ERCP with balloon dilation and stenting is the standard first-line treatment for post-transplant biliary anastomotic strictures.

Question 111: During a routine UNOS audit, an investigator notes that a transplant center documented a 'directed living donation' but the donor and recipient are not biologically related and no documentation of Independent Donor Advocate (IDA) involvement exists. Which regulatory standard is MOST directly implicated?

42 CFR §121.9, which requires HLA typing for all living donors regardless of relationship
OPTN Policy 18, which mandates IDA involvement for all living donors who are not first-degree biological relatives
42 CFR §482.98, which prohibits directed donation between unrelated individuals without prior CMS waiver
OPTN Policy 18, which requires IDA involvement for all non-directed and emotionally related living donors (Correct answer)

Correct answer: OPTN Policy 18, which requires IDA involvement for all non-directed and emotionally related living donors

OPTN Policy 18 requires that an Independent Donor Advocate be involved for living donors who are not genetically related (including emotionally related donors such as friends or spouses) and for all non-directed (altruistic) donors. The IDA's role is to protect the donor's interests independently from the transplant team. A directed donation to an unrelated recipient without IDA documentation violates this requirement. There is no CMS waiver process described in option D, and option B incorrectly limits the requirement to non-first-degree relatives.

Question 112: During discharge education for a kidney transplant recipient, you review signs of rejection. The patient asks, 'What if I feel completely fine — does that mean rejection isn't happening?' Which response BEST reflects current clinical understanding?

Feeling well is a reliable indicator that rejection is not occurring, since rejection universally presents with pain, fever, and oliguria
Asymptomatic periods are expected and mean the graft is tolerating the immune system, so routine monitoring is less critical during these times
Subclinical rejection, detectable only on protocol biopsy, can occur without any symptoms and still cause progressive allograft injury over time (Correct answer)
Rejection is always preceded by a measurable rise in serum creatinine that will cause noticeable fatigue before becoming clinically silent

Correct answer: Subclinical rejection, detectable only on protocol biopsy, can occur without any symptoms and still cause progressive allograft injury over time

Subclinical rejection — histologic evidence of rejection without clinical symptoms or significant creatinine rise — is a well-established phenomenon in renal transplantation. It is detected on protocol biopsies and, if untreated, contributes to chronic allograft nephropathy. Patients must understand that feeling well does not exclude active immune-mediated injury. Creatinine is an insensitive marker for early rejection and can remain normal despite ongoing subclinical damage.

Question 113: An 8-year-old child is listed for liver transplantation secondary to biliary atresia with progressive synthetic dysfunction. Her clinical team calculates her priority score. Which scoring system applies, and which variable included in that system does NOT appear in the standard adult MELD formula?

MELD-Na; serum sodium is the pediatric-specific variable added to account for fluid dysregulation unique to children
PELD; serum alpha-fetoprotein is the pediatric-specific biomarker substituted for creatinine, which is unreliable in young children
PELD; growth failure (height or weight more than 2 standard deviations below the mean for age and sex) is a variable that adds points and has no equivalent in the adult MELD formula (Correct answer)
MELD; creatinine is replaced by cystatin C in candidates under age 12, reflecting more accurate GFR estimation in pediatric patients

Correct answer: PELD; growth failure (height or weight more than 2 standard deviations below the mean for age and sex) is a variable that adds points and has no equivalent in the adult MELD formula

PELD (Pediatric End-Stage Liver Disease) applies to liver candidates under 12 years of age. Like MELD, it incorporates INR and bilirubin, but PELD replaces creatinine with albumin and adds two pediatric-specific variables: age <1 year (adds ~0.436 points) and growth failure — defined as height or weight >2 standard deviations below the age- and sex-adjusted mean — which adds approximately 0.667 points. Neither growth failure nor albumin appears in the standard MELD or MELD-Na formula, making growth failure the most uniquely pediatric element.

Question 114: A liver transplant candidate is listed Status 1A due to acute liver failure with a MELD score of 40. The patient's condition improves significantly, and their MELD score drops to 22 over 7 days. According to OPTN policy, what is the transplant coordinator's most appropriate action regarding the patient's waitlist status?

The coordinator can maintain Status 1A listing for up to 21 days regardless of clinical improvement
The coordinator must remove or relist the patient at the appropriate MELD-based status, as Status 1A requires ongoing re-certification every 7 days meeting specific criteria (Correct answer)
The coordinator must request a regional review board exception to maintain Status 1A listing
The patient automatically reverts to MELD score-based allocation; no coordinator action is required

Correct answer: The coordinator must remove or relist the patient at the appropriate MELD-based status, as Status 1A requires ongoing re-certification every 7 days meeting specific criteria

OPTN policy requires that Status 1A listing for acute liver failure must be re-certified every 7 days. The criteria for Status 1A are stringent and include specific clinical parameters (e.g., fulminant hepatic failure with life expectancy <7 days without transplant, on ventilator, on dialysis, or with Glasgow Coma Score <10). If the patient no longer meets these criteria due to clinical improvement, the coordinator must update the listing to reflect the current MELD score. Allowing a patient to remain at Status 1A when criteria are no longer met is a policy violation and could constitute fraud.

Question 115: A simultaneous kidney-pancreas transplant recipient presents 6 weeks post-transplant with fever, new-onset ascites, and a blood culture growing Candida glabrata (now reclassified as Nakaseomyces glabrata). Echocardiography is negative for endocarditis. The patient received fluconazole prophylaxis post-operatively. Which antifungal agent and duration represent current best practice for this presentation?

An echinocandin (e.g., caspofungin or micafungin) as initial therapy with de-escalation guided by susceptibility testing; continue for minimum 14 days after last positive blood culture and resolution of signs (Correct answer)
Voriconazole is preferred over echinocandins for C. glabrata candidemia due to superior CNS penetration protecting against late hematogenous seeding
Liposomal amphotericin B for 6 weeks regardless of susceptibility, as solid organ transplant recipients with Candida peritonitis require extended polyene therapy
Fluconazole 800 mg loading dose then 400 mg daily for 14 days after first negative blood culture, since C. glabrata is uniformly susceptible to high-dose fluconazole

Correct answer: An echinocandin (e.g., caspofungin or micafungin) as initial therapy with de-escalation guided by susceptibility testing; continue for minimum 14 days after last positive blood culture and resolution of signs

Nakaseomyces glabrata (formerly Candida glabrata) has intrinsically reduced susceptibility to fluconazole and a high rate of acquired azole resistance, especially following fluconazole prophylaxis — making empiric fluconazole inappropriate. Current IDSA guidelines recommend echinocandins (caspofungin, micafungin, or anidulafungin) as first-line therapy for candidemia, with candidemia treated for a minimum of 14 days after the first negative blood culture and clinical resolution. Susceptibility testing should guide de-escalation; some isolates also carry echinocandin resistance (FKS mutations), so follow-up cultures are essential.

Question 116: A liver transplant recipient's adult child insists on being present during all post-transplant education sessions and frequently answers questions on behalf of the patient. The patient appears passive and avoids eye contact when the family member is present. Which is the most appropriate initial intervention by the transplant coordinator?

Reinforce to the family member that the patient must respond independently during education
Continue with joint sessions since family support improves post-transplant adherence
Involve the social worker immediately and document family dysfunction in the medical record
Schedule a separate one-on-one education session with the patient alone to assess understanding and autonomy (Correct answer)

Correct answer: Schedule a separate one-on-one education session with the patient alone to assess understanding and autonomy

The patient's passive behavior and avoidance of eye contact may indicate coercion, fear, or dependence that undermines informed consent and self-management. The priority is to assess the patient's actual comprehension and autonomous understanding in a private setting before drawing conclusions or escalating. This protects patient autonomy while gathering more information. Directly confronting the family member or immediately involving social work without first assessing the patient alone is premature.

Question 117: A 45-year-old heart transplant candidate with ischemic cardiomyopathy (EF 18%) is on optimal medical therapy including an LVAD (HeartMate 3) implanted 14 months ago. He develops new-onset right heart failure with a right ventricular stroke work index (RVSWI) of 0.25 mmHg·L/m². Which of the following best characterizes the implication for transplant candidacy?

Severe fixed pulmonary hypertension must be ruled out, as LVAD support should have normalized PVR if reversible; persistent RV failure may indicate primary RV dysfunction incompatible with transplant (Correct answer)
Right heart failure on LVAD support is always managed by up-titrating diuresis and does not affect transplant listing status
RVSWI of 0.25 mmHg·L/m² is within normal limits and the right heart failure is likely LVAD device malfunction
The finding necessitates immediate LVAD explant before transplant evaluation can continue

Correct answer: Severe fixed pulmonary hypertension must be ruled out, as LVAD support should have normalized PVR if reversible; persistent RV failure may indicate primary RV dysfunction incompatible with transplant

RVSWI < 0.25 mmHg·L/m² (this patient is at the threshold of severe RV dysfunction) in a patient on LVAD support is critically important. LVAD should unload the left ventricle and reduce pulmonary pressures over time — if PVR does not normalize or RV failure develops despite LVAD, it suggests either fixed pulmonary hypertension or intrinsic right ventricular failure. Both significantly increase post-transplant primary graft failure risk. This demands right heart catheterization with vasodilator challenge to distinguish fixed from reversible disease. LVAD explant is not indicated and would be lethal. RVSWI < 0.25 is below normal, not within it.

Question 118: When a deceased donor organ becomes available, the UNOS/OPTN computer system generates a match run. Which of the following factors is given the highest priority in the allocation of most organs to ensure equity?

Medical urgency and compatibility (e.g., blood type, body size). (Correct answer)
The length of time the transplant coordinator has been at the center.
The transplant center's geographic preference.
The recipient's socioeconomic status or celebrity status.

Correct answer: Medical urgency and compatibility (e.g., blood type, body size).

The foundation of the OPTN/UNOS allocation system is to distribute organs based on objective medical criteria to ensure fairness. Key factors include medical urgency, blood type compatibility, body size match between donor and recipient, and tissue typing. Social or financial status is strictly prohibited from influencing allocation.

Question 119: An intestinal transplant recipient (isolated small bowel, day 21 post-transplant) undergoes surveillance ileoscopy. Biopsy of the neoterminal ileum shows diffuse crypt apoptosis with >6 apoptotic bodies per 10 crypts, crypt dropout, and villous blunting. There is no viral cytopathic effect on hematoxylin and eosin staining, and CMV immunohistochemistry is negative. The NEXT most appropriate diagnostic step is:

Treat empirically for acute cellular rejection with high-dose IV methylprednisolone
Send mucosal tissue for EBV in situ hybridization (EBER) and adenovirus immunohistochemistry or PCR (Correct answer)
Obtain serum donor-specific antibodies and perform C4d staining to rule out antibody-mediated rejection
Send stool EBV viral load to evaluate for post-transplant lymphoproliferative disorder involving the graft

Correct answer: Send mucosal tissue for EBV in situ hybridization (EBER) and adenovirus immunohistochemistry or PCR

In intestinal transplantation, the histologic differential for diffuse crypt apoptosis without viral cytopathic effect includes acute cellular rejection, adenovirus enteritis, and EBV-associated mucosal disease. CMV has been excluded. Adenovirus is a major cause of graft loss in intestinal recipients and can mimic rejection histologically — it must be excluded before empiric rejection treatment, as steroids would worsen adenoviral disease. EBV EBER staining evaluates for mucosal EBV replication distinct from PTLD. The correct next step is tissue-level viral workup (adenovirus IHC/PCR and EBER), NOT empiric steroid treatment. Treating presumed rejection without excluding adenovirus is a high-risk error unique to intestinal transplant management.

Question 120: During post-transplant surveillance, a kidney-pancreas transplant recipient at 18 months has a reactive IGRA (interferon-gamma release assay) result with a negative chest X-ray and no symptoms. They have no prior history of TB treatment. The transplant team decides to initiate LTBI treatment. Which scenario would warrant DELAYING isoniazid initiation in this patient?

Serum creatinine of 1.6 mg/dL with stable graft function
Concurrent use of mycophenolate mofetil 1000 mg twice daily
Tacrolimus trough level of 8 ng/mL in the therapeutic range
ALT level of 68 U/L (approximately 1.5× upper limit of normal) with no symptoms (Correct answer)

Correct answer: ALT level of 68 U/L (approximately 1.5× upper limit of normal) with no symptoms

Isoniazid (INH) is hepatotoxic, and current guidelines recommend caution or delay of INH initiation when baseline transaminases exceed 3× the upper limit of normal (ULN) in symptomatic patients, or 5× ULN in asymptomatic patients. An ALT of 68 U/L (~1.5× ULN) is below these thresholds and alone would not mandate delay. However, in transplant recipients on calcineurin inhibitors and antimetabolites with already stressed hepatic metabolism, an ALT at 1.5× ULN warrants investigation of the cause before starting INH — this borderline elevation may signal early hepatic injury that could be worsened. Among the choices presented, the elevated ALT is the only one that represents a hepatic signal requiring evaluation before proceeding. The other options (stable tacrolimus, mycophenolate, mild creatinine elevation) do not directly contraindicate INH initiation.

Question 121: A simultaneous kidney-pancreas (SPK) transplant recipient presents on post-operative day 4 with rising serum amylase, decreasing urine amylase (in a bladder-drained pancreas), low-grade fever, and tenderness over the pancreatic graft. Serum creatinine is stable. Which etiology must be excluded FIRST given that it carries the highest immediate risk of graft loss?

Anastomotic leak at the duodenocystostomy
Graft pancreatitis from preservation injury
Pancreatic venous thrombosis (Correct answer)
Acute cellular rejection of the pancreas

Correct answer: Pancreatic venous thrombosis

Pancreatic venous thrombosis must be excluded first because it is rapidly catastrophic and irreversible — the pancreas has no collateral venous drainage, so thrombosis leads to hemorrhagic infarction and graft loss within hours if untreated. Decreasing urine amylase in a bladder-drained SPK recipient is a critical early warning sign of pancreatic hypoperfusion or venous outflow obstruction. Doppler ultrasound or CT angiography should be performed immediately. Rejection, preservation pancreatitis, and anastomotic leak are all important considerations but evolve more slowly and allow more time for diagnosis and intervention.

Question 122: During pre-transplant evaluation, a living kidney donor candidate reveals that the intended recipient—their adult child—has threatened to end contact with the family if the candidate does not donate. The transplant team's independent donor advocate (IDA) suspects coercion. Which action is MOST consistent with ethical standards and the transplant coordinator's role?

Decline the candidacy immediately and document coercion without further assessment
Proceed with donation workup since the candidate verbally affirms willingness to donate
Conduct separate, confidential follow-up interviews with the candidate outside the presence of the recipient and family, specifically assessing voluntariness and freedom from undue pressure (Correct answer)
Refer the matter solely to the ethics committee without additional psychosocial assessment by the coordinator

Correct answer: Conduct separate, confidential follow-up interviews with the candidate outside the presence of the recipient and family, specifically assessing voluntariness and freedom from undue pressure

ASTS and UNOS guidelines require that living donor evaluation include robust screening for coercion, and that the donor candidate be assessed independently from the recipient and family. Verbal affirmation of willingness is insufficient when contextual red flags exist. The coordinator and IDA must conduct private, structured assessments to ensure the decision is autonomous, informed, and free from undue influence. Declining without thorough assessment or deferring entirely to ethics without completing the psychosocial evaluation would both be premature.

Question 123: During discharge education, a transplant coordinator explains the importance of sun protection. What is the primary reason transplant recipients must limit sun exposure?

Chronic immunosuppression significantly increases skin cancer risk (Correct answer)
Sunburn triggers acute rejection episodes
UV light worsens graft-versus-host disease
Sun causes immunosuppressant medications to break down

Correct answer: Chronic immunosuppression significantly increases skin cancer risk

Long-term immunosuppression dramatically elevates the risk of skin malignancies, especially squamous cell carcinoma, making sun protection essential.

Question 124: Which of the following is required for a legal declaration of brain death in a potential organ donor?

A reversible cause of coma
Irreversible cessation of all brain functions including the brainstem (Correct answer)
Presence of pupillary response to light
Preservation of spinal cord reflexes

Correct answer: Irreversible cessation of all brain functions including the brainstem

Brain death requires documented irreversible loss of all brain functions, including brainstem activity, confirmed by clinical examination and apnea testing.

Question 125: A 38-year-old prospective living kidney donor has a GFR of 78 mL/min/1.73m² and is found to have a solitary right renal artery aneurysm measuring 6mm on CTA. She has no hypertension and her 24-hour urine protein is 145mg. Which factor is MOST likely to result in donor exclusion?

The GFR value falling below the standard threshold for donation
Borderline proteinuria approaching the 150mg/day cutoff
The renal artery aneurysm size and location (Correct answer)
The combination of mildly reduced GFR with proteinuria representing additive risk

Correct answer: The renal artery aneurysm size and location

A renal artery aneurysm ≥6mm is typically considered a contraindication to donation due to surgical risk during nephrectomy and risk of rupture in the remaining kidney over the donor's lifetime. A GFR of 78 mL/min/1.73m² is within acceptable range for many programs (threshold is typically <80 adjusted for age and sex, but evaluated contextually). Proteinuria at 145mg is near but not over the 150–200mg/day cutoff. The aneurysm is the single most disqualifying anatomic finding here.

Question 126: A living liver donor candidate is a 29-year-old male whose volumetric CT analysis shows a projected remnant liver volume (RLV) of 29% of total liver volume. He has no hepatic steatosis and normal LFTs. The recipient requires a right lobe graft. What is the most accurate statement about proceeding?

An RLV of 29% meets the standard threshold of ≥30% and the donor may proceed without further consideration
The 29% RLV is acceptable because the recipient's need for a right lobe graft takes precedence over donor safety thresholds
An RLV of 29% falls below the widely accepted minimum of 30% for a healthy donor, and surgery should not proceed unless volumetric reassessment or surgical planning can increase the projected remnant (Correct answer)
RLV thresholds apply only to donors with steatosis; in a donor with normal liver function, any RLV above 20% is acceptable

Correct answer: An RLV of 29% falls below the widely accepted minimum of 30% for a healthy donor, and surgery should not proceed unless volumetric reassessment or surgical planning can increase the projected remnant

The widely accepted minimum RLV for a healthy living liver donor undergoing right hepatectomy is ≥30% (some centers require ≥35%). A remnant of 29% places the donor below this threshold, significantly increasing risk of post-hepatectomy liver failure (PHLF). Recipient need never overrides donor safety minimums — this is a foundational ethical principle in living donation. In a donor with steatosis, the required RLV minimum is even higher (often ≥40%). Options may include modified surgical planning, waiting for natural hepatic regeneration, or identifying an alternative donor.

Question 127: What is the primary purpose of the independent donor advocate (IDA) in the living donor evaluation process?

To ensure the donor's interests are represented separately from the transplant team (Correct answer)
To advocate for the recipient's need for a transplant
To expedite the evaluation timeline for the transplant center
To coordinate insurance coverage for the donor's surgery

Correct answer: To ensure the donor's interests are represented separately from the transplant team

The IDA is specifically designated to protect and represent the donor's interests, independent of the transplant team's goals.

Question 128: A lung transplant recipient is mechanically ventilated 10 hours after bilateral sequential transplantation. The ventilator team documents worsening oxygenation with PaO₂/FiO₂ ratio of 140, bilateral ground-glass infiltrates on CXR, and bronchoscopy showing diffuse erythema and frothy secretions bilaterally. BAL cultures are pending. The MOST accurate classification of this clinical picture and its primary pathophysiology is:

Acute fibrinous and organizing pneumonia (AFOP) representing an atypical early rejection pattern
Neurogenic pulmonary edema from donor brain death catecholamine surge persisting post-transplant
Grade 3 primary graft dysfunction (PGD) driven by ischemia-reperfusion injury activating innate immune pathways (Correct answer)
Hyperacute rejection caused by recipient anti-HLA antibodies binding donor pulmonary endothelium

Correct answer: Grade 3 primary graft dysfunction (PGD) driven by ischemia-reperfusion injury activating innate immune pathways

A PaO₂/FiO₂ <200 at 48–72 hours post-transplant with bilateral infiltrates meeting the ISHLT criteria constitutes Grade 3 PGD, the most severe form. Its pathophysiology centers on ischemia-reperfusion injury activating complement, neutrophil infiltration, reactive oxygen species release, and endothelial disruption — all innate immune mechanisms occurring independently of adaptive HLA responses. Hyperacute rejection (antibody-mediated) is possible but would be expected much earlier and is not the primary classification here without DSA confirmation. Neurogenic pulmonary edema from donor catecholamine surge does not persist 10 hours post-implant in the recipient. AFOP is a histologic diagnosis seen in later rejection episodes, not in the immediate postoperative window.

Question 129: A pediatric liver transplant recipient (7 years old, 22 kg) who received a left lateral segment living-donor graft is 36 hours post-transplant. The transplant coordinator reviews labs: tacrolimus trough 18.2 ng/mL (target 10–15), serum creatinine 1.8 mg/dL (baseline 0.5 mg/dL), urine output 0.6 mL/kg/hour, and blood pressure 148/92 mmHg. The patient is afebrile with good bile output. Which intervention is MOST appropriate?

Switch tacrolimus to cyclosporine to reduce nephrotoxic risk while maintaining adequate immunosuppression
Initiate IV hydration with normal saline at 1.5× maintenance and recheck electrolytes in 6 hours
Add amlodipine for hypertension management and continue tacrolimus unchanged, attributing the creatinine rise to ATN
Hold the next tacrolimus dose and recheck the trough in 12 hours before resuming at a reduced dose (Correct answer)

Correct answer: Hold the next tacrolimus dose and recheck the trough in 12 hours before resuming at a reduced dose

The tacrolimus trough of 18.2 ng/mL is supratherapeutic, and the clinical picture — acute kidney injury, hypertension, and oliguria — is consistent with calcineurin inhibitor nephrotoxicity. The correct management is to hold the next dose and recheck the level after a 12-hour drug-free interval before resuming at a lower dose, allowing the trough to fall into the therapeutic window. Treating hypertension with amlodipine without addressing the underlying tacrolimus toxicity perpetuates the renal injury. IV hydration may support renal perfusion but does not address the primary cause. Switching to cyclosporine is not indicated for initial tacrolimus toxicity management and would introduce additional complexity; dose adjustment is the first-line approach.

Question 130: Which of the following immunological tests is performed to determine a transplant candidate's sensitization to a broad panel of potential donor antigens?

Cytomegalovirus (CMV) serology
Panel Reactive Antibody (PRA) screening (Correct answer)
ABO blood typing
Human Leukocyte Antigen (HLA) typing

Correct answer: Panel Reactive Antibody (PRA) screening

Panel Reactive Antibody (PRA) screening is used to test the recipient's serum for antibodies against a panel of cells representing the general donor population. A high PRA indicates a high degree of sensitization, which can make finding a compatible donor more difficult and increases the risk of rejection. HLA typing identifies the specific antigens of the recipient, ABO typing determines blood group compatibility, and CMV serology checks for past exposure to cytomegalovirus.

Question 131: A liver transplant recipient with a history of non-adherence asks why they must take tacrolimus at the exact same time every day. Which pharmacokinetic principle is the MOST critical to emphasize in your educational response?

Tacrolimus has a narrow therapeutic index and highly variable absorption, making consistent timing essential to prevent trough level fluctuations that risk rejection or toxicity (Correct answer)
Consistent dosing times reduce the risk of drug-drug interactions with common foods like grapefruit by spacing doses from mealtimes
Tacrolimus has a long half-life of 72 hours, and consistent timing helps maintain predictable peak serum levels for monitoring purposes
Tacrolimus is a prodrug that must be activated by hepatic enzymes on a circadian rhythm, so timing aligns with peak enzyme activity

Correct answer: Tacrolimus has a narrow therapeutic index and highly variable absorption, making consistent timing essential to prevent trough level fluctuations that risk rejection or toxicity

Tacrolimus has a narrow therapeutic index and highly variable intra-patient and inter-patient absorption. Inconsistent timing leads to unpredictable trough levels, which can cause either sub-therapeutic immunosuppression (rejection risk) or supratherapeutic toxicity (nephrotoxicity, neurotoxicity). It is not a prodrug activated by circadian hepatic enzymes, and its half-life is approximately 12 hours, not 72. While grapefruit interactions are real, they are not the primary pharmacokinetic reason for strict timing.

Question 132: Which lung function parameter is the primary determinant when evaluating a potential lung donor for suitability?

Diffusing capacity (DLCO)
Residual volume
FEV1/FVC ratio
PaO2/FiO2 ratio (P/F ratio) ≥300 (Correct answer)

Correct answer: PaO2/FiO2 ratio (P/F ratio) ≥300

A P/F ratio ≥300 on 100% FiO2 and 5 cmH2O PEEP indicates adequate gas exchange and donor lung viability.

Question 133: A transplant coordinator is teaching a post-transplant recipient about pet safety. Which pet is associated with a specific infectious risk due to Toxoplasma gondii exposure?

Cats (Correct answer)
Birds
Fish
Dogs

Correct answer: Cats

Cat feces can contain Toxoplasma gondii oocysts; transplant recipients should avoid changing cat litter or wear gloves and wash hands thoroughly if contact is unavoidable.

Question 134: A transplant program's MPSC review flags the program for a 1-year patient survival rate that falls below the expected threshold for two consecutive review periods. The program has submitted a written response with a corrective action plan. If the MPSC determines the response is inadequate, what is the MOST likely next escalation step under OPTN bylaws?

Referral to the OPTN Board of Directors for imposition of a membership sanction, which may include required inactive status (Correct answer)
Automatic suspension of the program's transplant activity pending a full CMS survey triggered by the MPSC finding
Mandatory external peer review by a CMS-designated accreditation organization such as The Joint Commission
Immediate decertification from Medicare, as two consecutive below-threshold periods constitute a deemed failure under 42 CFR §482.80

Correct answer: Referral to the OPTN Board of Directors for imposition of a membership sanction, which may include required inactive status

Under OPTN bylaws, when the MPSC (Membership and Professional Standards Committee) finds a program's corrective action response inadequate after flagging for outcome deficiencies, it escalates the matter to the OPTN Board of Directors. The Board has authority to impose membership sanctions, including required inactive status (a suspension of transplant activity). Automatic CMS survey, Joint Commission external review, and Medicare decertification are not the direct next steps — CMS may independently act, but the OPTN escalation path runs through its own governance structure.

Question 135: Which diagnostic procedure is typically used to evaluate Cardiac Allograft Vasculopathy (CAV) in heart transplant recipients?

Echocardiography
Magnetic resonance angiography (MRA)
Left heart catheterization (Correct answer)
Coronary artery bypass graft (CABG)

Correct answer: Left heart catheterization

Explanation: <br> Left heart catheterization is commonly used to assess Cardiac Allograft Vasculopathy (CAV) in heart transplant recipients by directly visualizing the coronary arteries and assessing for any abnormalities or signs of vasculopathy. This procedure allows for accurate diagnosis and monitoring of cardiac health post-transplant.

Question 136: A patient is being evaluated for placement on the national transplant waiting list. Which of the following is a primary responsibility of the transplant coordinator during the pre-listing phase?

Contacting the donor's family directly to request organ donation.
Surgically performing the organ transplant.
Independently determining the final organ allocation sequence.
Ensuring the patient completes a comprehensive evaluation and understands the informed consent process for listing. (Correct answer)

Correct answer: Ensuring the patient completes a comprehensive evaluation and understands the informed consent process for listing.

The transplant coordinator is responsible for guiding the patient through the extensive pre-transplant evaluation, ensuring all necessary medical and psychosocial assessments are completed. A critical part of this role is educating the patient and obtaining informed consent for being placed on the UNOS waiting list. The other options describe roles of the surgeon, the OPTN's computerized system, and the Organ Procurement Organization (OPO) staff, respectively.

Question 137: A transplant coordinator is conducting a psychosocial re-evaluation of a lung transplant candidate who was previously deferred for active alcohol use disorder (AUD). The patient provides documentation of 12-step meeting attendance for 9 months but declines to provide collateral information from family members or agree to random ethanol biomarker testing (EtG/EtS). Which interpretation BEST reflects evidence-based psychosocial risk stratification?

Meeting attendance documentation alone constitutes sufficient evidence of sustained sobriety for re-listing consideration
The patient should be listed provisionally with the understanding that non-disclosure will be addressed post-transplant
The patient's right to privacy supersedes the transplant team's need for verification, so listing should proceed based on self-report
Refusal to provide collateral or consent to biomarker monitoring is a significant risk indicator that warrants continued deferral, as it limits the team's ability to verify sobriety and assess relapse risk (Correct answer)

Correct answer: Refusal to provide collateral or consent to biomarker monitoring is a significant risk indicator that warrants continued deferral, as it limits the team's ability to verify sobriety and assess relapse risk

Evidence-based psychosocial risk stratification for AUD in transplant candidates requires multimodal verification of sobriety: self-report, collateral information, and objective biomarker testing. Refusal of collateral and biomarker consent is not merely a preference issue—it is a clinically meaningful risk indicator that limits the team's ability to assess true sobriety duration, detect denial, and plan appropriate post-transplant monitoring. 12-step attendance documents engagement but not abstinence. Continued deferral pending willingness to participate in full evaluation is appropriate.

Question 138: A lung transplant recipient 3 years post-bilateral sequential transplant develops an FEV1 decline of 22% from baseline confirmed on two occasions 3 weeks apart, along with an obstructive spirometric pattern and no response to bronchodilators, with bronchoscopy showing no infection. CT chest reveals air-trapping and mosaic attenuation without bronchiectasis. What is the MOST likely diagnosis and its ISHLT classification?

Acute fibrinous and organizing pneumonia (AFOP), a form of acute rejection requiring pulse steroids
Restrictive allograft syndrome (RAS), a subtype of CLAD with a worse prognosis than BOS
Bronchiolitis obliterans syndrome (BOS) Grade 2, representing chronic lung allograft dysfunction (Correct answer)
Azithromycin-responsive allograft dysfunction (ARAD), which requires antibiotic escalation before CLAD diagnosis

Correct answer: Bronchiolitis obliterans syndrome (BOS) Grade 2, representing chronic lung allograft dysfunction

BOS Grade 2 is defined by an FEV1 of 51–65% of baseline (a 22% decline from baseline, if baseline FEV1 was sufficient, places this in Grade 2), obstructive physiology not reversible with bronchodilators, and exclusion of infection. Air-trapping and mosaic attenuation on CT are consistent with small airway disease (BOS). RAS is characterized by a restrictive pattern (TLC reduction) and upper-lobe fibrosis — the obstructive spirometry here argues against it. AFOP is a histopathologic diagnosis associated with acute allograft dysfunction, not the chronic progressive presentation described. ARAD should be excluded before diagnosing CLAD but the question states no infection found and the pattern is obstructive/chronic.

Question 139: A local celebrity receives a transplant at your center. A reporter calls the transplant coordinator asking for an update, claiming to have a signed authorization from the patient's publicist. What is the coordinator's most appropriate and HIPAA-compliant next step?

Provide the requested information since an authorization was mentioned.
Refer the call to the hospital's designated Public Relations or Media Affairs department. (Correct answer)
Ask the reporter to fax the authorization directly to the transplant office for review.
State that providing information is against policy under all circumstances.

Correct answer: Refer the call to the hospital's designated Public Relations or Media Affairs department.

Under HIPAA, protected health information (PHI) can be released to the media with a valid, patient-signed authorization. However, the responsibility for verifying the authenticity and scope of such authorizations, especially for high-profile cases, rests with the hospital's designated department (e.g., Public Relations). The coordinator's correct action is to route the inquiry through the proper institutional channels, not to verify the authorization themselves or release information without verification.

Question 140: As part of the educational process for living donors and transplant candidates, what should be discussed regarding potential transplant drug regimens?

Only the benefits of the drugs
Only the cost of the medications
None of the potential effects
Potential side effects and effects on daily life (Correct answer)

Correct answer: Potential side effects and effects on daily life

Explanation: <br> It's crucial to discuss potential side effects and how transplant drug regimens may affect the daily lives of living donors and transplant candidates. This ensures they have a comprehensive understanding of the medications they will need to take post-transplant and can make informed decisions about their healthcare journey.

Question 141: The National Organ Transplant Act (NOTA) of 1984 expressly prohibits which of the following actions?

Listing a patient at more than one transplant center.
Using social media to solicit living organ donors.
Directed donation from a deceased donor to a specified individual.
The transfer of any human organ for valuable consideration. (Correct answer)

Correct answer: The transfer of any human organ for valuable consideration.

The National Organ Transplant Act (NOTA) is the foundational federal law that established the framework for the U.S. organ transplant system. A central tenet of this act is the criminalization of the sale and purchase of human organs, making it illegal to transfer any human organ for "valuable consideration." The other options are either permitted (multiple listing, social media solicitation) or allowed under specific OPTN policies (directed donation).

Question 142: Which of the following topics is MOST critical to include in the immediate post-transplant discharge education for a heart transplant recipient regarding infection prevention?

Proper hand hygiene and avoiding large crowds and sick individuals. (Correct answer)
The schedule for future routine vaccinations.
Long-term dietary restrictions related to cardiovascular health.
The importance of annual skin cancer screenings.

Correct answer: Proper hand hygiene and avoiding large crowds and sick individuals.

In the immediate post-transplant period, the patient is most vulnerable to opportunistic infections due to high levels of immunosuppression. Therefore, education on fundamental infection prevention strategies like meticulous hand hygiene and avoiding exposure to pathogens by staying away from crowds and sick contacts is the most critical and time-sensitive topic. Vaccinations, skin screenings, and long-term diet are important but are typically addressed in more detail later in the post-transplant course.

Question 143: The MOST important preventive measure a transplant coordinator can reinforce to reduce surgical site infection (SSI) after transplant surgery is:

Taking prophylactic broad-spectrum antibiotics indefinitely
Avoiding all contact with other people for 6 months
Strict hand hygiene and proper wound care as instructed by the surgical team (Correct answer)
Avoiding all physical activity for 12 months

Correct answer: Strict hand hygiene and proper wound care as instructed by the surgical team

Hand hygiene and proper wound assessment/care are the most evidence-based interventions to prevent SSI and should be reinforced at every post-operative visit.

Question 144: A renal transplant coordinator is managing a deceased-donor kidney that has been accepted by a recipient center. The kidney was procured from a donor after circulatory death (DCD — Maastricht category III). Cold ischemia time is approaching 22 hours. The recipient center is 4 hours away. Which perfusion strategy is MOST strongly supported by evidence to mitigate the elevated risk of delayed graft function (DGF) in this scenario?

Use normothermic machine perfusion (NMP) at 37°C with oxygenated packed red blood cells to fully restore aerobic metabolism during transport
Employ hypothermic machine perfusion (HMP) with oxygenated perfusate (HOPE or oHMP) to reduce ischemia-reperfusion injury compared to static cold storage (Correct answer)
Proceed with static cold storage and accept the elevated DGF risk, as outcomes are equivalent to hypothermic machine perfusion beyond 18 hours
Discard the kidney if cold ischemia will exceed 24 hours, as DCD kidneys beyond this threshold have unacceptable primary non-function rates

Correct answer: Employ hypothermic machine perfusion (HMP) with oxygenated perfusate (HOPE or oHMP) to reduce ischemia-reperfusion injury compared to static cold storage

DCD kidneys are particularly susceptible to ischemia-reperfusion injury due to the warm ischemia sustained before circulatory arrest. Hypothermic machine perfusion (HMP) — and specifically oxygenated HMP (HOPE protocol) — has demonstrated superiority over static cold storage in randomized trials (including the COPE trial) for reducing DGF, improving early graft function, and in some analyses improving 1-year graft survival in DCD kidneys. HMP maintains cell viability by providing continuous substrate delivery and waste removal at low temperatures. Normothermic machine perfusion (NMP/37°C) is a valid emerging technology but requires full oxygenated blood circuit setup and is logistically complex; it is used for viability assessment and reconditioning rather than routine extended transport. Static cold storage at 22+ hours for a DCD kidney has well-documented inferior outcomes. Discarding a potentially viable kidney solely based on CIT approaching 24 hours without trial of machine perfusion would be inappropriate.

Question 145: Epstein-Barr virus (EBV) reactivation post-transplant is most concerning because it is associated with the development of:

Hepatitis C recurrence
Cytomegalovirus retinitis
Post-transplant lymphoproliferative disorder (PTLD) (Correct answer)
BK nephropathy

Correct answer: Post-transplant lymphoproliferative disorder (PTLD)

EBV-driven B-cell proliferation under immunosuppression can lead to PTLD, a potentially life-threatening malignancy that ranges from benign hyperplasia to aggressive lymphoma.

Question 146: A simultaneous liver-kidney transplant candidate presents with a MELD score of 34 and significant hepatic encephalopathy. During psychosocial evaluation, he intermittently cannot recall the names of his medications or his transplant surgeon, but accurately describes why he needs a transplant and agrees to proceed. His wife provides a reliable social support history. Which statement BEST characterizes the coordinator's assessment approach regarding consent capacity?

Hepatic encephalopathy is a categorical contraindication to self-consent; the evaluation should document this and proceed under surrogate authorization
The patient should be re-evaluated for capacity only after lactulose therapy is optimized and encephalopathy grades improve to Grade I
Capacity assessment should focus on the patient's ability to understand the nature of transplant, appreciate consequences, reason about options, and communicate a consistent choice — not on factual recall per se (Correct answer)
The patient lacks decision-making capacity because he cannot recall specific medication names, and surrogate consent should be pursued

Correct answer: Capacity assessment should focus on the patient's ability to understand the nature of transplant, appreciate consequences, reason about options, and communicate a consistent choice — not on factual recall per se

Legal and ethical standards for decision-making capacity (Appelbaum's four criteria) require understanding, appreciation, reasoning, and communication of a consistent choice — not flawless factual recall. Medication name recall is a memory task, not a capacity criterion. Hepatic encephalopathy is not a categorical bar to capacity; patients fluctuate, and capacity must be evaluated at the time of the decision. Re-evaluating after treatment may be clinically prudent but is not the standard that defines the assessment approach described.

Question 147: A lung transplant recipient on voriconazole prophylaxis for aspergillus develops breakthrough invasive aspergillosis 6 months post-transplant. Bronchoalveolar lavage culture grows Aspergillus fumigatus. The transplant team is considering salvage therapy. Which resistance mechanism is MOST commonly associated with azole-refractory A. fumigatus, and which drug class is the preferred salvage agent?

CYP51A (cyp51A) gene mutations causing triazole resistance; isavuconazole or amphotericin B-based salvage with azole susceptibility testing (Correct answer)
Efflux pump overexpression without CYP51A mutation; switch to anidulafungin monotherapy
Beta-glucan synthase upregulation; high-dose posaconazole IV
Acquired echinocandin resistance (fks mutations); combination voriconazole plus caspofungin

Correct answer: CYP51A (cyp51A) gene mutations causing triazole resistance; isavuconazole or amphotericin B-based salvage with azole susceptibility testing

Azole resistance in A. fumigatus is predominantly driven by mutations in the CYP51A gene (encoding the target enzyme of triazoles), with TR34/L98H being the most epidemiologically significant tandem repeat mutation linked to environmental azole exposure. In breakthrough aspergillosis on voriconazole prophylaxis, resistance testing (susceptibility/MIC determination) is essential. Salvage therapy typically involves a drug from a different class — liposomal amphotericin B or isavuconazole (if susceptibility confirms activity) — or combination therapy. Echinocandins have limited monotherapy efficacy against Aspergillus and are used adjunctively. Efflux pumps are a minor resistance mechanism in Aspergillus. Posaconazole IV is not salvage when pan-azole resistance is suspected.

Question 148: A 58-year-old patient with end-stage renal disease secondary to IgA nephropathy is being evaluated for kidney transplant. His eGFR is 9 mL/min. During psychosocial evaluation, he discloses he stopped attending dialysis sessions twice in the past month due to "feeling fine." Which of the following is the most appropriate next step in the pre-transplant evaluation process?

Refer the patient for formal psychiatric evaluation and defer listing until adherence patterns are reassessed over a defined observation period (Correct answer)
Decline listing permanently due to non-adherence, as this is an absolute contraindication per UNOS policy
Proceed with listing immediately, as occasional missed dialysis sessions are common and not predictive of post-transplant outcomes
List the patient but add a notation in the chart and require monthly adherence check-ins with the transplant coordinator

Correct answer: Refer the patient for formal psychiatric evaluation and defer listing until adherence patterns are reassessed over a defined observation period

Non-adherence to dialysis is a significant predictor of post-transplant medication non-adherence and graft loss. The appropriate response is not outright permanent declination (non-adherence is a relative, not absolute, contraindication) nor proceeding without action. A structured psychosocial evaluation with a defined observation period allows the team to assess whether barriers are correctable (e.g., depression, transportation, health literacy) before making a listing decision.

Question 149: A kidney transplant recipient is started on a standard postoperative regimen of high-dose corticosteroids and tacrolimus. The transplant coordinator should be vigilant in monitoring the patient for which common metabolic side effect?

Hypoglycemia
Hyperglycemia (Correct answer)
Hypokalemia
Hyponatremia

Correct answer: Hyperglycemia

Both high-dose corticosteroids and tacrolimus have significant diabetogenic effects. Corticosteroids induce insulin resistance, while tacrolimus is directly toxic to pancreatic beta-cells, impairing insulin secretion. The combination puts the patient at high risk for developing hyperglycemia and new-onset diabetes after transplantation (NODAT).

Question 150: A kidney transplant recipient's biopsy confirms acute antibody-mediated rejection (AMR) with C4d staining and circulating donor-specific antibodies (DSAs). In addition to optimizing maintenance immunosuppression, which therapy is specifically aimed at the physical removal of the pathogenic circulating antibodies?

High-dose intravenous corticosteroids
Plasmapheresis (Plasma Exchange) (Correct answer)
Rituximab
Antithymocyte globulin (ATG)

Correct answer: Plasmapheresis (Plasma Exchange)

Plasmapheresis, or plasma exchange, is a therapeutic procedure that directly removes antibodies, including DSAs, from the patient's bloodstream. While corticosteroids, ATG, and Rituximab are used to treat AMR by modulating the immune response (targeting T-cells and B-cells), only plasmapheresis physically removes the existing antibodies causing the damage.

Question 151: A transplant candidate on the kidney waiting list presents to the emergency department of a hospital where they are not listed, complaining of fever and shortness of breath. Under the Emergency Medical Treatment and Active Labor Act (EMTALA), what is the hospital's primary obligation?

To contact the patient's transplant coordinator to get permission to treat.
To refuse treatment because the patient is not on their transplant waitlist.
To immediately transfer the patient back to their listing transplant center.
To provide a medical screening examination and necessary stabilizing treatment. (Correct answer)

Correct answer: To provide a medical screening examination and necessary stabilizing treatment.

EMTALA requires any Medicare-participating hospital with an emergency department to provide a medical screening examination (MSE) to any individual seeking emergency care to determine if an emergency medical condition exists. If an emergency condition is found, the hospital must provide stabilizing treatment within its capabilities, regardless of the patient's ability to pay or their transplant listing status. A transfer should only be considered after these steps are taken.

Question 152: Which finding on abdominal imaging would most concern the transplant team when evaluating a liver transplant candidate?

Mild splenomegaly
Small gallstones without cholecystitis
Portal vein thrombosis extending into the superior mesenteric vein (Correct answer)
Small volume ascites responsive to diuretics

Correct answer: Portal vein thrombosis extending into the superior mesenteric vein

Extensive portal vein thrombosis involving the superior mesenteric vein significantly complicates liver transplant surgery and may be a contraindication.

Question 153: A 38-year-old kidney transplant recipient is maintained on belatacept-based immunosuppression. At month 10 post-transplant, MRI reveals a solitary enhancing cerebral lesion; biopsy confirms EBV-positive monomorphic post-transplant lymphoproliferative disorder (PTLD). Which pre-transplant factor MOST directly conferred this patient's elevated risk for this specific complication?

EBV-seronegative recipient status at the time of transplant (Correct answer)
Prior treatment with antithymocyte globulin for induction therapy
Panel reactive antibody (PRA) greater than 80% requiring desensitization
CMV donor-positive/recipient-negative serostatus mismatch

Correct answer: EBV-seronegative recipient status at the time of transplant

Belatacept carries a Black Box Warning for PTLD, with the highest risk in EBV-seronegative recipients. Belatacept blocks CD28-B7 costimulation, impairing EBV-specific cytotoxic T-lymphocyte (CTL) surveillance. In EBV-seronegative recipients who lack pre-formed EBV-specific memory T cells, primary EBV infection post-transplant can drive uncontrolled B-cell proliferation in the absence of effective CTL control. Belatacept is contraindicated in EBV-seronegative transplant recipients for this reason. CMV mismatch is a risk factor for CMV disease, not EBV-related PTLD.

Question 154: A liver transplant candidate with a history of alcohol use disorder has maintained sobriety for 18 months. During psychosocial assessment, the patient's spouse privately discloses to the transplant coordinator that the patient resumed drinking 3 weeks ago but is hiding it. The patient adamantly denies any relapse during the formal interview. What is the most appropriate next step?

Immediately remove the patient from the transplant waiting list pending a 90-day sobriety re-evaluation period
Respect patient confidentiality and disregard the spouse's report since it is unverified hearsay
Document the collateral disclosure, confer with the multidisciplinary team, and arrange a dedicated session with the social worker and addiction specialist before advancing candidacy (Correct answer)
Inform the patient directly during the interview that the spouse reported a relapse and request a response

Correct answer: Document the collateral disclosure, confer with the multidisciplinary team, and arrange a dedicated session with the social worker and addiction specialist before advancing candidacy

Collateral information from family members is a clinically valid and important data source in transplant psychosocial assessment. The coordinator has an ethical obligation to the patient's long-term outcomes and the equitable allocation of organs. The appropriate step is to document the disclosure, bring it to the multidisciplinary team (transplant hepatologist, social worker, addiction specialist), and conduct a structured follow-up evaluation—which may include urine/blood alcohol screening—before transplant candidacy proceeds. Disregarding the report violates the team's duty of thorough assessment; immediate listing removal without investigation is premature; and confronting the patient mid-interview without team guidance is not within the coordinator's individual scope.

Question 155: A transplant candidate is found to have a positive PPD skin test with no prior BCG vaccination and no active symptoms. What is the appropriate management?

Rifampin therapy for 6 months prior to listing
Prophylactic isoniazid (INH) therapy before and after transplant (Correct answer)
Immediate removal from the transplant waitlist
No treatment needed unless active disease develops post-transplant

Correct answer: Prophylactic isoniazid (INH) therapy before and after transplant

Latent TB identified by positive PPD without prior BCG warrants prophylactic INH to prevent reactivation after immunosuppression.

Question 156: In evaluating a candidate for kidney transplantation, which of the following findings is considered a relative contraindication that requires careful assessment and management rather than an absolute one?

Metastatic lung cancer
Uncontrolled sepsis
Morbid obesity (BMI > 40 kg/m²) (Correct answer)
Severe, irreversible cardiac disease

Correct answer: Morbid obesity (BMI > 40 kg/m²)

Morbid obesity is generally considered a relative contraindication to transplantation. While it increases surgical risk and can impact graft function, it may be managed through weight loss programs before transplant. In contrast, active infections like uncontrolled sepsis, active malignancies, and severe, uncorrectable cardiopulmonary disease are considered absolute contraindications because they pose an unacceptably high risk of mortality or immediate graft failure.

Question 157: A heart transplant candidate has a panel reactive antibody (PRA) of 85%. What is the primary clinical implication?

Automatic removal from the waiting list
Reduced risk of acute rejection
High likelihood of hyperacute rejection without prospective crossmatch (Correct answer)
Requirement for ABO-incompatible transplant protocol

Correct answer: High likelihood of hyperacute rejection without prospective crossmatch

A high PRA indicates broad sensitization to HLA antigens, significantly increasing the risk of hyperacute rejection if a prospective crossmatch is not performed.

Question 158: Which factor is NOT directly used to calculate the Lung Allocation Score (LAS)?

Recipient's geographic proximity to donor hospital (Correct answer)
Predicted post-transplant survival benefit
Disease diagnosis group
Predicted waitlist survival without transplant

Correct answer: Recipient's geographic proximity to donor hospital

The LAS is calculated from waitlist urgency and transplant benefit measures including diagnosis group, but geographic proximity is a separate matching criterion, not an LAS component.

Question 159: A kidney transplant recipient on tacrolimus, mycophenolate mofetil, and prednisone presents 4 years post-transplant with new-onset proteinuria (2.8 g/day), rising creatinine, and a biopsy showing C4d-negative transplant glomerulopathy with donor-specific antibodies (DSAs) detected. Which management strategy is most strongly supported by current evidence for this presentation?

Optimize tacrolimus levels, consider rituximab or IVIg-based desensitization, and refer for re-transplant evaluation given poor long-term allograft survival (Correct answer)
Convert to belatacept-based regimen combined with intravenous immunoglobulin and plasmapheresis to reduce DSA burden
Switch mycophenolate mofetil to azathioprine and add eculizumab as first-line complement inhibition
Increase tacrolimus trough targets to 10–12 ng/mL and add rituximab to address antibody-mediated injury

Correct answer: Optimize tacrolimus levels, consider rituximab or IVIg-based desensitization, and refer for re-transplant evaluation given poor long-term allograft survival

Chronic active antibody-mediated rejection (cAMR) with transplant glomerulopathy and persistent DSAs carries a poor prognosis with a median allograft half-life of 2–5 years after diagnosis. No single intervention has proven highly effective in reversing established glomerulopathy. Optimization of immunosuppression, DSA-reduction strategies (rituximab, IVIg, plasmapheresis), and early re-transplant planning are recommended by international guidelines (KDIGO 2022). Simply increasing tacrolimus to supratherapeutic levels increases toxicity without addressing antibody-mediated pathology, and eculizumab is not first-line for C4d-negative cAMR.

Question 160: During pre-transplant cardiac evaluation, a liver transplant candidate with non-ischemic cardiomyopathy has an echocardiogram showing an ejection fraction of 35% and a mean pulmonary artery pressure (mPAP) of 38 mmHg with pulmonary vascular resistance (PVR) of 3.5 Wood units. Which statement BEST reflects current AASLD/UNOS guidance regarding this candidate's transplant eligibility?

A dobutamine stress echocardiogram should replace right heart catheterization findings as the primary eligibility determinant
Portopulmonary hypertension is confirmed; the candidate may qualify for MELD exception points if mPAP is reduced to below 35 mmHg with therapy (Correct answer)
The candidate is absolutely contraindicated for liver transplant due to reduced ejection fraction below 40%
The candidate should be listed immediately because PVR below 4 Wood units is the only determinant of eligibility

Correct answer: Portopulmonary hypertension is confirmed; the candidate may qualify for MELD exception points if mPAP is reduced to below 35 mmHg with therapy

This patient meets diagnostic criteria for portopulmonary hypertension (PoPH): elevated mPAP ≥25 mmHg in the setting of portal hypertension. Current guidance from AASLD and UNOS/OPTN allows MELD exception points for PoPH candidates who achieve mPAP <35 mmHg and PVR <5 Wood units with vasodilator therapy, as these thresholds are associated with acceptable post-transplant outcomes. An mPAP of 35–44 mmHg with PVR ≥5 Wood units is a relative contraindication, while mPAP ≥45 mmHg is an absolute contraindication. The EF alone does not absolutely contraindicate listing; cardiology-guided optimization is attempted. Right heart catheterization remains the gold standard over echo-estimated values for final listing decisions.

Question 161: A transplant program's QAPI committee discovers that its 1-year kidney graft survival rate has fallen below the MPSC flagging threshold for two consecutive flagging periods. The program has submitted a Systems Improvement Agreement (SIA). Which of the following actions is MOST consistent with CMS Conditions of Participation requirements during the SIA review period?

The program must suspend all transplant activity until the SIA is formally approved by UNOS/MPSC
The program may continue transplanting while implementing the corrective action plan outlined in the SIA (Correct answer)
The program must obtain written CMS approval before transplanting any Status 1A or 1B candidates
The program may continue transplanting but must report any adverse outcomes within 24 hours to CMS

Correct answer: The program may continue transplanting while implementing the corrective action plan outlined in the SIA

Under UNOS/MPSC oversight, submission of a Systems Improvement Agreement does not automatically suspend a program's transplant activity. The program continues operating while implementing its corrective action plan, which is monitored by the MPSC. Suspension is a separate, more serious action reserved for situations where patient safety is in immediate jeopardy, not merely for statistical underperformance addressed through an SIA.

Question 162: A transplant center has a policy of listing only patients who have stable housing. Which ethical principle is most in tension with this policy?

Non-maleficence
Veracity
Beneficence
Justice (Correct answer)

Correct answer: Justice

Requiring stable housing as a listing criterion may systematically disadvantage socioeconomically vulnerable patients, raising justice concerns about equitable access.

Question 163: A non-directed (altruistic) living donor is undergoing assessment. As part of the informed consent process, which of the following points is uniquely critical to discuss with this type of donor?

The fact that the transplant program will determine the recipient of the organ. (Correct answer)
The potential for post-operative pain and the plan for its management.
The requirement for post-donation follow-up care at 6, 12, and 24 months.
The possibility of surgical complications like infection or bleeding.

Correct answer: The fact that the transplant program will determine the recipient of the organ.

While all donors must be informed about surgical risks, follow-up care, and recovery, it is uniquely important for a non-directed donor to understand that they have no control over who receives their organ. The transplant center's allocation policies, based on factors like the recipient's medical urgency and compatibility, will determine the recipient. This lack of influence over the organ's destination is a key component of the consent process for altruistic donors.

Question 164: A lung transplant recipient (bilateral) is 30 hours post-transplant and requires FiO₂ of 0.85 to maintain SpO₂ of 91%, with PaO₂/FiO₂ ratio of 108. Chest X-ray shows bilateral infiltrates. BAL fluid is clear and cultures are pending. The CXR appearance is symmetric. Which intervention has the STRONGEST evidence for improving outcomes specifically in primary graft dysfunction Grade 3 after lung transplantation?

High-dose systemic corticosteroids (methylprednisolone 1g IV)
Prone positioning for 16 hours per day
Venovenous ECMO as a bridge to recovery (Correct answer)
Empiric broad-spectrum antibiotics covering donor-transmitted organisms

Correct answer: Venovenous ECMO as a bridge to recovery

Primary graft dysfunction (PGD) Grade 3 (PaO₂/FiO₂ <200 within 72 hours) is the most severe form of ischemia-reperfusion injury in lung transplantation. When refractory to conventional ventilatory support, venovenous ECMO has the strongest evidence as a rescue strategy — it offloads the graft, allows lung-protective ventilation, and serves as a bridge to recovery or re-transplantation. High-dose corticosteroids lack strong evidence for PGD and may increase infection risk in the immediate post-transplant window. Empiric antibiotics address infection (a separate diagnosis) but not PGD pathophysiology. Prone positioning has robust evidence in native ARDS but has not been validated specifically for PGD Grade 3 in transplant recipients.

Question 165: Under the Kidney Allocation System (KAS), what does the Estimated Post-Transplant Survival (EPTS) score primarily reflect?

The recipient's immune sensitization level
The likelihood of a candidate dying on the waitlist within 5 years
The recipient's predicted long-term graft survival (Correct answer)
The donor's organ quality based on Kidney Donor Profile Index

Correct answer: The recipient's predicted long-term graft survival

EPTS predicts how long a recipient is expected to benefit from a transplanted kidney, helping match longer-surviving kidneys to candidates expected to live longest.

Question 166: A transplant candidate has an intellectual disability with a supportive guardian and stable home environment. How should the team approach candidacy evaluation?

Automatically deny listing based on intellectual disability
List the candidate without additional evaluation
Require guardianship transfer to the hospital before proceeding
Conduct an individualized assessment of functional capacity, support system strength, and ability to adhere to the post-transplant regimen (Correct answer)

Correct answer: Conduct an individualized assessment of functional capacity, support system strength, and ability to adhere to the post-transplant regimen

Intellectual disability is not an automatic contraindication; UNOS non-discrimination policies require individualized assessment based on medical suitability and support system adequacy.

Question 167: A kidney transplant recipient, 6 hours postoperative, experiences a sudden decrease in urine output from 150 mL/hr to less than 20 mL/hr. The patient's blood pressure and central venous pressure are stable. What is the MOST appropriate initial action for the transplant coordinator to anticipate?

Sending a urine sample for culture and sensitivity.
Administration of an intravenous fluid bolus.
Obtaining an urgent renal ultrasound with Doppler. (Correct answer)
Preparing for emergent hemodialysis.

Correct answer: Obtaining an urgent renal ultrasound with Doppler.

A sudden drop in urine output in a patient with stable hemodynamics is highly suspicious for a vascular or urological emergency. An urgent renal ultrasound with Doppler is the most critical first step to rule out renal artery or vein thrombosis, or a ureteral obstruction, which would require immediate surgical intervention. While fluid status is important, stable CVP makes severe hypovolemia less likely. Infection is unlikely to cause such an abrupt change this early, and dialysis would only be considered after a cause for the oliguria is determined.

Question 168: A patient listed Status 1A for heart transplant has a psychiatric history including a suicide attempt 14 months ago. A donor heart becomes available and is a strong match. The patient is currently sedated on ECMO and cannot participate in the consent discussion. His documented advance directive names his estranged adult daughter as healthcare proxy. The daughter states she refuses the heart on her father's behalf, citing her belief that his psychiatric history means he 'wouldn't really want to live.' Which response best reflects the transplant coordinator's ethical and legal obligations?

Seek urgent ethics committee consultation and, if the daughter's decision appears to substitute her own values rather than apply substituted judgment, pursue legal review of proxy authority while preserving the organ offer if possible (Correct answer)
Honor the daughter's refusal, as she is the legally designated healthcare proxy and her decision is binding regardless of the team's clinical assessment
Contact the patient's outpatient psychiatrist to override the proxy's refusal, as psychiatric providers have the authority to countermand surrogate decisions involving mental health history
Proceed with transplant over the daughter's objection after obtaining emergent court authorization, because a history of psychiatric illness does not legally disqualify a patient from receiving an organ

Correct answer: Seek urgent ethics committee consultation and, if the daughter's decision appears to substitute her own values rather than apply substituted judgment, pursue legal review of proxy authority while preserving the organ offer if possible

A healthcare proxy must apply substituted judgment — what the patient would want — not the proxy's own values. A refusal based on a biased interpretation of psychiatric history ('he wouldn't want to live') is a red flag that the proxy may not be applying the correct legal and ethical standard. The appropriate response is urgent ethics consultation and possible judicial review of proxy authority, not unilateral override by the team or dismissal of the concern. Psychiatric history alone is not a contraindication to transplant listing or acceptance, and the proxy's role does not authorize value-substitution.

Question 169: During pre-transplant evaluation for a simultaneous liver-kidney (SLK) transplant, the team is deliberating whether a patient with acute kidney injury superimposed on chronic kidney disease meets UNOS criteria for SLK listing. The patient's eGFR has been 28 mL/min at baseline (CKD Stage 3b) with a recent nadir of 14 mL/min during hepatorenal syndrome type 1. Which criterion is MOST critical in determining SLK eligibility under current UNOS policy?

A single eGFR measurement below 30 mL/min taken during the index hospitalization for hepatorenal syndrome
Kidney biopsy demonstrating greater than 30% glomerulosclerosis as a prerequisite for all SLK listings
Sustained reduction in kidney function defined as eGFR ≤60 mL/min for ≥90 consecutive days, or eGFR ≤30 mL/min at time of liver transplant evaluation, or ESRD on dialysis (Correct answer)
Any episode of acute kidney injury requiring dialysis for more than 6 weeks regardless of baseline kidney function

Correct answer: Sustained reduction in kidney function defined as eGFR ≤60 mL/min for ≥90 consecutive days, or eGFR ≤30 mL/min at time of liver transplant evaluation, or ESRD on dialysis

UNOS's 2017 SLK allocation policy established medical eligibility criteria requiring: eGFR ≤60 mL/min for ≥90 days, OR eGFR ≤30 mL/min at evaluation, OR ESRD (on dialysis ≥90 days). Transient AKI during HRS, even requiring short-term dialysis, does not automatically qualify a patient for SLK without meeting sustained chronicity criteria. A biopsy is not mandated by policy, though it may inform clinical decision-making. The 90-day sustained dysfunction requirement protects kidneys for patients with true ESRD.

Question 170: A liver transplant candidate has portopulmonary hypertension with right heart catheterization showing a mean pulmonary arterial pressure (mPAP) of 38 mmHg and pulmonary vascular resistance (PVR) of 4.5 Wood units. After 4 months of targeted pulmonary arterial hypertension (PAH) therapy, repeat catheterization demonstrates mPAP of 33 mmHg and PVR of 2.8 Wood units. Which statement BEST characterizes this patient's transplant candidacy?

PAH therapy must be discontinued before listing to confirm that hemodynamic improvement is not treatment-dependent
The patient requires combined heart-lung transplantation because portopulmonary hypertension cannot be safely managed with liver transplant alone
The patient remains an absolute contraindication to transplant because the initial mPAP exceeded 35 mmHg at the time of diagnosis
The patient may now be considered for transplant listing, as mPAP has responded below 35 mmHg and PVR has normalized to an acceptable range (Correct answer)

Correct answer: The patient may now be considered for transplant listing, as mPAP has responded below 35 mmHg and PVR has normalized to an acceptable range

For portopulmonary hypertension, what matters is hemodynamic response to therapy, not the initial values. When mPAP falls below 35 mmHg and PVR normalizes (generally <240 dynes·s·cm⁻⁵ or approximately <3 Wood units) with treatment, the patient may be considered for liver transplant listing with careful perioperative management. The initial mPAP does not constitute a permanent absolute contraindication if it responds to PAH therapy (A). Heart-lung transplant is not required in this well-responding patient (C). Withdrawing PAH therapy pre-operatively would be dangerous and is not standard practice (D).

Question 171: Transplant recipients are at a significantly increased risk for developing certain malignancies due to long-term immunosuppression. Which of the following cancers has the highest incidence in the post-transplant population?

Post-transplant lymphoproliferative disorder (PTLD)
Prostate cancer
Colorectal cancer
Non-melanoma skin cancer (Correct answer)

Correct answer: Non-melanoma skin cancer

Long-term immunosuppression dramatically increases the risk for many cancers, with non-melanoma skin cancers (squamous cell and basal cell carcinoma) being the most common malignancy by a significant margin. While PTLD risk is also highly elevated compared to the general population, its absolute incidence is lower than that of skin cancers.

Question 172: During psychosocial evaluation of a paired/kidney exchange donor, the transplant coordinator discovers the donor originally came forward to donate to a specific recipient but was redirected to the exchange chain. The donor now expresses hesitation about donating to a stranger. Under UNOS policy, which statement is most accurate?

The donor may withdraw only before the original recipient receives a transplant; afterward, withdrawal is prohibited
The donor retains the unconditional right to withdraw consent at any point, even mid-chain, without penalty (Correct answer)
Withdrawal mid-chain is permissible only if the donor provides a medical reason accepted by the transplant team
The donor is obligated to complete the chain once the original recipient has received a kidney from another chain donor

Correct answer: The donor retains the unconditional right to withdraw consent at any point, even mid-chain, without penalty

UNOS policy and ethical principles firmly establish that living donors retain the unconditional right to withdraw consent at any time, for any reason, without penalty or coercion — including mid-chain in a paired exchange. Centers must not apply pressure on the basis of chain integrity or recipient outcomes. Protecting donor autonomy supersedes logistical or chain-completion concerns, and the donor's hesitation must be taken seriously and explored without coercion.

Question 173: A living-donor kidney transplant is being planned for a waitlisted candidate. What happens to the candidate's waitlist time upon living-donor transplant?

Wait time is preserved and can be used if the living-donor transplant fails and re-listing occurs (Correct answer)
Wait time resets to zero regardless of prior waiting period
Wait time is permanently forfeited upon acceptance of the living-donor organ
Wait time transfers to a family member who needs transplant

Correct answer: Wait time is preserved and can be used if the living-donor transplant fails and re-listing occurs

OPTN policy allows candidates to retain accrued waitlist time, so if a living-donor kidney fails and they must return to the waitlist, prior wait time can be credited.

Question 174: A liver transplant recipient on tacrolimus (trough 6 ng/mL), mycophenolate mofetil 1g BID, and prednisone 5 mg/day is 5 years post-transplant. She is started on rifampin for latent TB prophylaxis after a positive IGRA. Her tacrolimus trough drops to 1.2 ng/mL within 10 days despite no dose change. The transplant coordinator's MOST appropriate immediate action is:

Add voriconazole to inhibit CYP3A4 and restore tacrolimus levels
Contact the physician to discuss switching rifampin to isoniazid and monitoring closely for rejection (Correct answer)
Increase tacrolimus empirically by 3-fold and recheck trough in 1 week
Discontinue mycophenolate to reduce overall immunosuppression while rifampin is continued

Correct answer: Contact the physician to discuss switching rifampin to isoniazid and monitoring closely for rejection

Rifampin is a potent inducer of CYP3A4 and P-glycoprotein, causing dramatic drops in tacrolimus levels (often 3–5 fold) that are difficult to manage even with dose escalation. The coordinator's role is to promptly alert the physician so the regimen can be reconsidered — isoniazid alone (if the organism is susceptible) avoids this interaction. Simply tripling the tacrolimus dose is unpredictable and risks toxicity when rifampin is stopped. Discontinuing mycophenolate increases rejection risk without solving the drug-level problem. Using voriconazole as a CYP inhibitor is not an appropriate strategy and creates its own interaction profile.

Question 175: Which of the following best defines Donation after Circulatory Death (DCD)?

Organ recovery from a living donor who undergoes planned cardiac arrest under anesthesia
Organ recovery following withdrawal of life-sustaining treatment and confirmation of circulatory arrest (Correct answer)
Organ recovery performed concurrently with active cardiopulmonary resuscitation efforts
Organ recovery from a donor who meets standard neurological brain death criteria

Correct answer: Organ recovery following withdrawal of life-sustaining treatment and confirmation of circulatory arrest

DCD (previously called non-heart-beating donation) involves procurement after withdrawal of life-sustaining therapy and confirmation of circulatory death. Unlike standard brain death donors where the heart continues beating until surgical procurement, DCD donors experience cardiac arrest first, resulting in warm ischemia time that affects organ viability assessments.

Certified Clinical Transplant Coordinator (CCTC)

The CCTC exam, administered by the American Board for Transplant Certification (ABTC), validates the clinical knowledge and competency of transplant coordinators involved in vascular organ transplantation including kidney, liver, heart, lung, pancreas, and intestine.

175

Questions

180 min

Time Limit

70%

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