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ABIM Tx Hepatology study materials
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ABIM Tx Hepatology practice questions

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Question 1Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which laboratory value is a component of the MELD 3.0 score used for liver transplant allocation in the United States?

  1. Platelet count
  2. Serum ammonia
  3. Serum sodium Correct answer.
  4. Serum lactate

Explanation

MELD 3.0 incorporates bilirubin, INR, creatinine, serum sodium, and albumin, together with a sex-based adjustment. Serum sodium was retained from MELD-Na because hyponatremia independently predicts waitlist mortality. Ammonia, lactate, and platelet count are prognostically relevant but are not part of the equation.

Question 2Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which tumor burden meets the Milan criteria for liver transplantation in hepatocellular carcinoma?

  1. A single lesion of 5 cm or up to three lesions each 3 cm Correct answer.
  2. A single lesion of 6 cm or up to two lesions each 4 cm
  3. A single lesion of 3 cm or up to three lesions each 2 cm
  4. Any number of lesions with a total diameter of 8 cm

Explanation

The Milan criteria permit a single tumor up to 5 cm, or up to three tumors each no larger than 3 cm, in the absence of macrovascular invasion and extrahepatic spread. Meeting these limits is associated with survival comparable to non-HCC indications. Several centers use expanded criteria, but Milan remains the standard reference set.

Question 3Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which finding is an absolute contraindication to liver transplantation?

  1. Hepatocellular carcinoma treated with ablation two years ago
  2. HIV infection with an undetectable viral load
  3. Active systemic infection that remains uncontrolled despite treatment Correct answer.
  4. Partial portal vein thrombosis

Explanation

Uncontrolled active infection precludes transplantation because immunosuppression would be unsafe and the operative risk is prohibitive. Infection must be controlled before a candidate can be activated on the waitlist. The other listed conditions are either manageable or represent acceptable risk after appropriate evaluation.

Question 4Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A 54-year-old with hepatitis C cirrhosis has well-controlled HIV infection. Which statement best reflects transplant eligibility?

  1. Transplantation requires documented HIV seroreversion before listing
  2. Transplantation requires a CD4 count above 500 cells per microliter
  3. Transplantation is reasonable when viremia is suppressed and CD4 counts are adequate Correct answer.
  4. Transplantation is contraindicated in all patients with HIV infection regardless of viral control

Explanation

HIV infection is no longer a contraindication when viral load is suppressed on antiretroviral therapy, CD4 counts are adequate, and there is no history of AIDS-defining opportunistic illness. Outcomes in carefully selected patients approach those of HIV-negative recipients. Antiretroviral interactions with immunosuppressants require dose adjustment but do not preclude transplant.

Question 5Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which body mass index is most commonly used as a threshold for relative contraindication to liver transplantation?

  1. A BMI greater than 33 kg/m²
  2. A BMI greater than 30 kg/m²
  3. A BMI greater than 40 kg/m² Correct answer.
  4. A BMI greater than 25 kg/m²

Explanation

A BMI above 40 kg/m² is generally regarded as a relative contraindication because of increased perioperative and wound complications, although selected patients are still transplanted. Values between 35 and 40 kg/m² are considered with comorbidity assessment. A BMI of 25 or 30 alone does not exclude candidacy.

Question 6Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

The MELD score used for allocation is bounded between which values?

  1. 6 and 40 Correct answer.
  2. 0 and 40
  3. 6 and 100
  4. 10 and 50

Explanation

Calculated MELD values are truncated so that the minimum is 6 and the maximum is 40. The floor prevents patients with only mild laboratory abnormalities from receiving inappropriately low scores. The ceiling compresses the sickest patients into a narrow range, which is one reason exception pathways exist.

Question 7Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which statement about chronologic age in candidate selection is correct?

  1. Age is incorporated directly into the MELD 3.0 calculation
  2. Age above 70 years is an absolute contraindication
  3. Age alone is not a contraindication, and physiologic reserve guides selection Correct answer.
  4. Age above 65 years requires a MELD exception

Explanation

There is no fixed upper age limit for liver transplantation. Programs assess frailty, sarcopenia, cardiopulmonary reserve, and comorbidity instead of chronologic age. Carefully selected older recipients achieve acceptable outcomes.

Question 8Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A patient with cirrhosis and no prior hepatitis B exposure is being evaluated for transplantation. Which vaccine should be given before transplant?

  1. Live attenuated intranasal influenza vaccine
  2. Hepatitis B vaccine Correct answer.
  3. Smallpox vaccine
  4. Yellow fever vaccine

Explanation

Hepatitis B vaccination is recommended for seronegative patients with chronic liver disease before transplant, because post-transplant immunosuppression and the use of hepatitis B core antibody-positive donors increase risk. Response is better when vaccination occurs before immunosuppression. Live vaccines are generally avoided in this population.

Question 9Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A patient with hepatitis C cirrhosis has a solitary 3 cm hepatocellular carcinoma without vascular invasion or extrahepatic disease and a calculated MELD of 10. What is the most appropriate allocation approach?

  1. Assign emergency status because of the malignancy
  2. No adjustment, because MELD already captures tumor burden
  3. Apply standardized MELD exception points reflecting waitlist mortality Correct answer.
  4. List immediately without any score adjustment

Explanation

MELD is based on synthetic and renal function and therefore underestimates mortality risk in patients with preserved liver function and a tumor. Standardized exception points, calibrated to local median MELD at transplant, correct this disparity. Emergency status is reserved for acute decompensation such as acute liver failure or primary graft nonfunction.

Question 10Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A patient with alcohol-associated cirrhosis has been abstinent for four months and has a favorable psychosocial assessment with strong family support and stable housing. Which statement best reflects current selection practice?

  1. Listing requires documented six months of continuous abstinence in every case
  2. Shorter abstinence may be acceptable when psychosocial risk assessment is favorable Correct answer.
  3. Abstinence duration is irrelevant and no psychosocial assessment is required
  4. Listing is permitted only after one year of documented abstinence

Explanation

The traditional six-month rule has been replaced in many programs by individualized psychosocial assessment. Patients with shorter abstinence but low predicted risk of relapse may be listed. Relapse prediction relies on substance use history, social support, and engagement in treatment rather than duration alone.

Question 11Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which statement about perihilar cholangiocarcinoma as an indication for liver transplantation is correct?

  1. It may be treated with transplantation only after five years of documented remission
  2. It may be treated with neoadjuvant chemoradiation under a research protocol Correct answer.
  3. It is managed with transplantation only when the MELD score exceeds 25
  4. It is an absolute contraindication at every center

Explanation

Highly selected patients with unresectable perihilar cholangiocarcinoma, typically 3 cm or smaller without intrahepatic or extrahepatic spread, may undergo neoadjuvant chemoradiation followed by transplantation at experienced centers under strict protocols. This approach achieves durable survival in well-selected cohorts. It is not a standard indication outside such protocols.

Question 12Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A 62-year-old with NASH cirrhosis, type 2 diabetes, and hypertension has no cardiac symptoms and is being evaluated for listing. Which cardiac evaluation is most appropriate?

  1. Exclude the patient because of the diabetes
  2. Perform noninvasive stress testing before listing Correct answer.
  3. Proceed directly to listing without cardiac evaluation
  4. Obtain a resting electrocardiogram only

Explanation

Candidates with multiple coronary risk factors, particularly diabetes and older age, should undergo noninvasive stress testing as part of transplant evaluation. Cirrhosis can mask ischemic symptoms and coronary disease increases perioperative mortality. Abnormal results prompt coronary angiography and possible revascularization.

Question 13Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A candidate with cirrhosis had breast cancer treated with surgery and chemotherapy six years ago with no evidence of recurrence. How should this affect transplant candidacy?

  1. Proceed with listing because the interval exceeds two years
  2. Exclude the patient permanently because of the cancer history
  3. Proceed with listing because the interval exceeds five years Correct answer.
  4. Delay listing until ten years have passed

Explanation

A prior extrahepatic malignancy generally requires a disease-free interval of about five years before transplantation, because immunosuppression can accelerate recurrence. Breast cancer treated with curative intent six years earlier with no recurrence meets this expectation. Some tumor types require longer intervals or are managed individually.

Question 14Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A candidate has a partially occlusive portal vein thrombus extending into the main portal vein. How should this influence transplant selection?

  1. It is not an absolute contraindication, and operative planning is individualized Correct answer.
  2. It requires an automatic MELD exception
  3. It mandates permanent exclusion from transplantation
  4. It requires simultaneous liver-kidney transplantation

Explanation

Portal vein thrombosis is common in cirrhosis and is no longer considered an absolute contraindication. Centers assess the extent of thrombus and may use thrombectomy, interposition grafts, or alternative inflow reconstruction. Extensive splanchnic thrombosis may make surgery technically infeasible, but that determination is individualized.

Question 15Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which psychosocial finding is generally considered a contraindication to liver transplantation?

  1. Support from a single involved family member
  2. Remote cannabis use more than ten years ago
  3. A history of treated major depression
  4. Active untreated substance use despite offered treatment Correct answer.

Explanation

Ongoing, untreated substance use that persists despite engagement efforts predicts relapse, graft loss, and nonadherence, and is widely regarded as a contraindication. Well-treated psychiatric illness, remote substance use, and modest but reliable support are not disqualifying. The assessment should be longitudinal rather than a single snapshot.

Question 16Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A patient with severe alcohol-associated hepatitis, no prior history of liver disease, strong family support, and no other organ failure is being considered for early liver transplantation. What is the most appropriate position?

  1. Transplantation should be offered only if the MELD score exceeds 35
  2. Transplantation is absolutely contraindicated until one year of abstinence is completed
  3. Transplantation should be offered only after steroid therapy fails for six months
  4. Early transplantation may be offered to carefully selected patients without a mandatory waiting period Correct answer.

Explanation

Selected patients with severe alcohol-associated hepatitis who have a first episode, no prior liver disease, strong social support, and no other organ failure may undergo early transplantation without a mandated abstinence period. Selection relies on psychosocial assessment and is performed at centers with established protocols. Outcomes in well-selected cohorts are comparable to standard indications.

Question 17Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which pulmonary condition is generally regarded as a contraindication to liver transplantation?

  1. Oxygen-dependent COPD with an FEV1 of 25% of predicted Correct answer.
  2. Obstructive sleep apnea treated with CPAP
  3. FEV1 of 65% of predicted with no oxygen requirement
  4. Well-controlled asthma requiring inhaled corticosteroids

Explanation

Severe chronic obstructive pulmonary disease with oxygen dependence or an FEV1 below roughly 30% of predicted carries prohibitive perioperative and long-term risk and is generally considered a contraindication. Mild to moderate airflow limitation and treated sleep apnea are acceptable. Pulmonary evaluation is particularly important because hepatic hydrothorax and hepatopulmonary syndrome also affect gas exchange.

Question 18Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which modification distinguishes MELD 3.0 from earlier MELD-based scores in an effort to reduce sex-based disparities?

  1. Serum sodium is weighted more heavily in men
  2. Age replaces albumin in the equation
  3. Female sex receives a fixed point adjustment Correct answer.
  4. Race is included as a model variable

Explanation

MELD 3.0 adds a fixed adjustment for female sex to account for differences in creatinine generation and body composition that historically disadvantaged women on the waitlist. It also incorporates albumin and retains sodium. Race is not a variable in the model.

Question 19Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

In living donor liver transplantation, what minimum graft-to-recipient weight ratio is generally required to avoid small-for-size syndrome?

  1. 0.8 or greater Correct answer.
  2. 0.3 or greater
  3. 0.5 or greater
  4. 0.6 or greater

Explanation

A graft-to-recipient weight ratio of at least 0.8, corresponding to roughly 40% of standard liver volume, is generally accepted as necessary to prevent small-for-size syndrome. Below this threshold, portal hyperperfusion causes graft dysfunction and cholestasis. Some centers prefer ratios of 1.0 or greater.

Question 20Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A candidate with cirrhosis has a mean pulmonary artery pressure of 42 mm Hg and pulmonary vascular resistance of 6 Wood units despite vasodilator therapy. How should this affect transplant candidacy?

  1. Transplantation may proceed if the MELD score is above 20
  2. Transplantation should not proceed because the pulmonary pressures exceed acceptable limits Correct answer.
  3. Transplantation may proceed with intraoperative nitric oxide alone
  4. Transplantation may proceed because mean pulmonary artery pressure is irrelevant

Explanation

Portopulmonary hypertension must be controlled before transplantation, generally requiring a mean pulmonary artery pressure below 35 mm Hg and pulmonary vascular resistance below 3 Wood units (240 dynes·s·cm⁻⁵) with preserved right ventricular function. Values above these thresholds carry prohibitive perioperative mortality. Vasodilator therapy may convert some patients into acceptable candidates over time.

Question 21Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which findings satisfy King's College criteria for transplantation in acetaminophen-induced acute liver failure?

  1. ALT of 5000 U/L, bilirubin of 5 mg/dL, and grade II encephalopathy
  2. INR of 2.5, creatinine of 1.5 mg/dL, and grade I encephalopathy
  3. INR of 4.0 with grade II encephalopathy alone
  4. Arterial pH of 7.25 after fluid resuscitation Correct answer.

Explanation

For acetaminophen-induced injury, King's College criteria include an arterial pH below 7.30 after adequate fluid resuscitation, or the combination of an INR above 6.5, creatinine above 3.4 mg/dL, and grade III or IV encephalopathy. A lactate level above 3.5 mmol/L early in the course is also used at some centers. Meeting criteria prompts urgent transplant evaluation.

Question 22Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A patient with hepatocellular carcinoma beyond Milan criteria undergoes locoregional therapy and is downstaged to a single 4 cm lesion with no viable residual tumor on imaging after six months. How should this be addressed in transplant selection?

  1. The patient remains permanently ineligible because the original tumor exceeded Milan
  2. Eligibility requires a MELD score above 20
  3. Eligibility requires an alpha-fetoprotein level above 1000 ng/mL
  4. Successful downstaging with a durable response may allow exception point consideration at many centers Correct answer.

Explanation

Downstaging to within Milan criteria followed by a sustained radiographic response is accepted at many centers as a basis for exception point consideration, although specific protocols vary. The rationale is that tumor biology, reflected by treatment response, predicts post-transplant recurrence better than initial size alone. Alpha-fetoprotein levels and MELD score are not eligibility determinants in this setting.

Question 23Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which patient with cirrhosis meets criteria for simultaneous liver-kidney transplantation?

  1. A patient with an eGFR of 55 mL/min/1.73 m² and stable creatinine
  2. A patient with an eGFR of 45 mL/min/1.73 m² and proteinuria of 200 mg/day
  3. A patient receiving hemodialysis for eight weeks with an eGFR of 20 mL/min/1.73 m² Correct answer.
  4. A patient with a single episode of prerenal azotemia that resolved with fluids

Explanation

Simultaneous liver-kidney transplantation is indicated for sustained kidney failure, defined by an eGFR at or below 30 mL/min/1.73 m² or dialysis for at least six weeks. Eight weeks of hemodialysis with an eGFR of 20 meets both thresholds. Transient or moderate renal impairment without sustained dysfunction does not qualify.

Question 24Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which finding qualifies a patient with hepatopulmonary syndrome for standardized MELD exception points?

  1. Oxygen saturation of 96% on room air
  2. Arterial partial pressure of oxygen below 60 mm Hg on room air Correct answer.
  3. Arterial partial pressure of oxygen of 75 mm Hg on room air
  4. Diffusing capacity of 70% of predicted

Explanation

Hepatopulmonary syndrome with an arterial partial pressure of oxygen below 60 mm Hg on room air in the presence of intrapulmonary shunting qualifies for MELD exception points because the score does not capture this mortality risk. Documentation typically requires contrast echocardiography and arterial blood gas analysis. Milder hypoxemia does not meet exception criteria.

Question 25Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which statement about frailty in liver transplant candidates is best supported?

  1. Frailty is captured by the MELD 3.0 equation
  2. Frailty is defined solely by the serum albumin level
  3. Frailty predicts waitlist mortality independent of the MELD score Correct answer.
  4. Frailty is only relevant after transplantation

Explanation

Physical frailty, measured by tools such as the Liver Frailty Index, predicts waitlist mortality and delisting independently of MELD. This occurs because MELD captures synthetic and renal function but not functional reserve. Frailty also predicts postoperative complications and is therefore used in candidate selection and prehabilitation.

Question 26Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which serum electrolyte was added to the original MELD score to create MELD-Na?

  1. Sodium Correct answer.
  2. Chloride
  3. Bicarbonate
  4. Potassium

Explanation

MELD-Na incorporates serum sodium because hyponatremia independently predicts waiting-list mortality in cirrhosis. The original MELD uses bilirubin, INR, and creatinine, so sodium is the added variable.

Question 27Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which condition is a standard indication for liver transplantation?

  1. Mild hepatic steatosis without fibrosis
  2. Asymptomatic gallstones without complications
  3. Isolated splenomegaly with normal liver tests
  4. Decompensated cirrhosis with MELD-Na 18 Correct answer.

Explanation

Liver transplantation is indicated for decompensated cirrhosis when expected benefit exceeds perioperative risk, and many programs use MELD-Na around 15 or greater as a threshold. Asymptomatic gallstones and mild steatosis without fibrosis do not by themselves cause decompensation.

Question 28Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which malignancy is generally an absolute contraindication to liver transplantation?

  1. Solitary hepatocellular carcinoma measuring 2 cm
  2. Metastatic colorectal adenocarcinoma Correct answer.
  3. Basal cell carcinoma of the skin
  4. T1a urothelial bladder cancer

Explanation

Extrahepatic malignancy with a high recurrence risk, such as metastatic colorectal adenocarcinoma, is generally an absolute contraindication. Curative-intent exceptions exist for some tumors after defined disease-free intervals, but metastatic disease is not compatible with acceptable posttransplant survival.

Question 29Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which finding is an absolute contraindication to liver transplantation in acute liver failure?

  1. Serum bilirubin of 8 mg/dL
  2. Irreversible brain injury Correct answer.
  3. INR of 2.0
  4. Grade II hepatic encephalopathy

Explanation

In acute liver failure, irreversible brain injury indicates that neurologic recovery is not expected and transplantation would be futile. The other listed abnormalities may influence prognosis but are not absolute contraindications by themselves.

Question 30Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A 45-year-old with decompensated cirrhosis and well-controlled HIV (undetectable viral load, CD4 350) is evaluated. Which statement is correct?

  1. Transplant is contraindicated because of immunosuppression
  2. CD4 count below 500 is an absolute contraindication
  3. HIV infection alone does not preclude transplantation Correct answer.
  4. HIV protease inhibitors must be stopped before listing

Explanation

HIV infection is not a contraindication when the virus is well controlled and the patient can tolerate antiretroviral therapy. Transplant programs coordinate antiretroviral regimens with immunosuppression and monitor viral load and CD4 counts.

Question 31Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A candidate with decompensated cirrhosis has a BMI of 46 kg/m2. Which statement best reflects transplant selection?

  1. Bariatric surgery must always be completed before transplant listing
  2. A BMI above 35 kg/m2 is an absolute contraindication to listing
  3. BMI is not considered during the transplant selection process
  4. Severe obesity is a relative contraindication Correct answer.

Explanation

Severe obesity is associated with higher surgical and perioperative risk, so it is treated as a relative rather than absolute contraindication. Selection is individualized and may include weight-management strategies and evaluation at experienced centers.

Question 32Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A candidate continues to smoke cigarettes actively during evaluation. Which statement is most accurate?

  1. Active smoking increases perioperative pulmonary risk Correct answer.
  2. Smoking status need not be addressed before listing
  3. Smoking only affects donor organ quality, not recipient risk
  4. Active smoking is an absolute contraindication to transplantation

Explanation

Active smoking increases perioperative pulmonary complications, infection, and wound-healing problems, so cessation is strongly advised before transplant. Smoking is usually a modifiable relative contraindication rather than an absolute bar.

Question 33Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

An HCV-negative candidate is offered a liver from an HCV-RNA-positive donor. Which statement is correct?

  1. HCV can be transmitted only if the donor has antibodies
  2. Treatment can begin only after severe hepatitis develops
  3. Direct-acting antivirals allow safe use of such grafts Correct answer.
  4. The graft is contraindicated because of universal HCV transmission

Explanation

Livers from HCV-RNA-positive donors can be used for HCV-negative recipients when direct-acting antiviral prophylaxis or early treatment is available. Cure rates are high, and this strategy expands the donor pool.

Question 34Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which statement about protein-calorie malnutrition in liver transplant candidates is correct?

  1. It predicts worse waitlist and transplant outcomes Correct answer.
  2. It is best assessed by serum albumin alone
  3. It should be treated by routine protein restriction
  4. It is unrelated to sarcopenia or frailty

Explanation

Protein-calorie malnutrition and sarcopenia are common in cirrhosis and predict higher waitlist mortality and worse posttransplant outcomes. Nutrition support should be provided, and protein is generally not restricted unless a specific contraindication exists.

Question 35Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which principle applies to living donor evaluation for liver transplantation?

  1. The recipient's need determines donor acceptability
  2. Donors require independent evaluation and no coercion Correct answer.
  3. Donor benefit is assumed if the recipient is a relative
  4. Donor age above 50 years is an absolute contraindication

Explanation

Living donation requires independent medical and psychosocial evaluation of the donor, with confirmation that consent is voluntary and free of coercion. The donor's safety and autonomy are separate from the recipient's need.

Question 36Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A patient with polycystic liver disease has massive hepatomegaly, early satiety, and poor quality of life despite cyst fenestration. MELD-Na is 10. Which statement is correct?

  1. Symptomatic mass effect can justify transplantation Correct answer.
  2. Transplant is precluded because MELD-Na is below 15
  3. Cyst fenestration must be repeated before listing
  4. Transplant is indicated only if dialysis is required

Explanation

Polycystic liver disease can cause severe mass-effect symptoms and poor quality of life that justify transplantation even when MELD-Na is low. Standard MELD exception pathways may apply because the score does not capture symptom burden.

Question 37Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which metabolic disorder is an accepted indication for liver transplantation?

  1. Transthyretin familial amyloid polyneuropathy Correct answer.
  2. Hereditary hemochromatosis with compensated cirrhosis
  3. Alpha-1 antitrypsin deficiency with emphysema only
  4. Gilbert syndrome with intermittent jaundice

Explanation

Transthyretin familial amyloid polyneuropathy is an accepted metabolic indication because the liver produces the mutant transthyretin. Transplantation replaces the source of the pathogenic protein in selected patients.

Question 38Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A patient with compensated cirrhosis has MELD-Na 11, no ascites, no variceal bleeding, and no HCC. Which statement about transplant evaluation is correct?

  1. Listing is not routinely indicated at MELD-Na 11 Correct answer.
  2. Only living donation is appropriate at this score
  3. MELD-Na 11 mandates immediate listing
  4. Transplant should proceed because cirrhosis is present

Explanation

Transplant evaluation is generally reserved for decompensated cirrhosis or a MELD-Na high enough to confer survival benefit, often around 15 or greater. A compensated patient with MELD-Na 11 and no HCC or complication is usually monitored rather than listed.

Question 39Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

Which surveillance strategy is recommended for a patient with cirrhosis awaiting transplant?

  1. Annual contrast-enhanced MRI of the abdomen
  2. CT of the abdomen every 3 months indefinitely
  3. Serum AFP testing alone every 12 months
  4. Ultrasound every 6 months with or without AFP Correct answer.

Explanation

Guidelines recommend liver ultrasound every 6 months, with or without AFP, for HCC surveillance in cirrhosis. More frequent or cross-sectional imaging is reserved for specific risk profiles or abnormal screening results.

Question 40Evaluation and selection of liver transplant candidates (indications, contraindications, MELD-based allocation, pretransplant management)

A patient with primary sclerosing cholangitis and ulcerative colitis is evaluated for liver transplantation. Which pretransplant screening is most important?

  1. Routine upper endoscopy every 3 months
  2. Annual bone density testing only
  3. Colonoscopy for dysplasia surveillance Correct answer.
  4. Annual serum CA 19-9 alone

Explanation

Primary sclerosing cholangitis with ulcerative colitis carries a markedly increased risk of colorectal dysplasia and cancer. Colonoscopy with dysplasia surveillance is therefore important before and after liver transplantation.

Question 41Perioperative and immediate postoperative care of the liver transplant recipient

Immediately after unclamping the portal vein and reperfusing a donor liver, the recipient becomes profoundly hypotensive, the heart rate falls to 40/min, the ECG shows peaked T waves, and serum potassium rises from 3.9 to 6.5 mEq/L. Which is the most likely explanation?

  1. Anaphylaxis to the perioperative antibiotic
  2. Tension pneumothorax from central line placement
  3. Post-reperfusion syndrome with hyperkalemia Correct answer.
  4. Acute adrenal insufficiency from steroid induction

Explanation

Post-reperfusion syndrome is a transient triad of hypotension, bradyarrhythmia, and hyperkalemia caused by washout of cold, acidotic, potassium-rich preservation fluid from the graft. Treatment centers on intravenous calcium, vasopressors, and volume, and it usually resolves within minutes.

Question 42Perioperative and immediate postoperative care of the liver transplant recipient

Which complication is most strongly associated with prolonged cold ischemia time in a liver allograft stored in static cold preservation?

  1. Recurrent hepatitis C
  2. Acute cellular rejection
  3. Ischemic-type biliary strictures Correct answer.
  4. Post-transplant lymphoproliferative disorder

Explanation

Cold storage injury disproportionately affects biliary epithelium, which depends on the hepatic artery, so prolonged cold ischemia predisposes to non-anastomotic strictures and dilatations known as ischemic-type biliary lesions. It also contributes to early allograft dysfunction, whereas rejection and lymphoproliferative disease are immune-mediated and unrelated to cold time.

Question 43Perioperative and immediate postoperative care of the liver transplant recipient

A 58-year-old with MELD 32 and a baseline eGFR of 28 mL/min/1.73 m² is undergoing liver transplantation. The team wants induction immunosuppression that avoids further nephrotoxicity and does not cause prolonged T-cell depletion. Which agent is most appropriate?

  1. High-dose tacrolimus started intraoperatively
  2. Antithymocyte globulin at depleting doses
  3. Basiliximab Correct answer.
  4. Muromonab-CD3

Explanation

Basiliximab is an interleukin-2 receptor antagonist that provides induction without nephrotoxicity or sustained lymphocyte depletion, which makes it well suited when calcineurin inhibitor initiation must be delayed for renal recovery. It is typically paired with mycophenolate and a later, lower-dose tacrolimus.

Question 44Perioperative and immediate postoperative care of the liver transplant recipient

Which prophylactic regimen is standard after liver transplantation to prevent Pneumocystis jirovecii pneumonia?

  1. Fluconazole for 6 months
  2. Trimethoprim-sulfamethoxazole for 6 to 12 months Correct answer.
  3. Azithromycin for the first postoperative month
  4. A 2-week course of aerosolized pentamidine

Explanation

Trimethoprim-sulfamethoxazole is first-line prophylaxis and additionally covers Toxoplasma and Nocardia; it is continued for at least 6 to 12 months, and longer with sustained heavy immunosuppression. Sulfa allergy is managed with dapsone, atovaquone, or aerosolized pentamidine as alternatives.

Question 45Perioperative and immediate postoperative care of the liver transplant recipient

On postoperative day 5 after liver transplantation, a patient develops fever, a sharp rise in transaminases, and dark bilious output from the surgical drain. Doppler ultrasound shows no flow in the proper hepatic artery. Which is the most likely diagnosis?

  1. Hepatic artery thrombosis Correct answer.
  2. Acute cellular rejection
  3. Cytomegalovirus hepatitis
  4. Biliary anastomotic stricture

Explanation

Early hepatic artery thrombosis produces graft ischemia with fever, marked transaminitis, and ischemic biliary necrosis or leak, because the donor biliary tree is perfused solely by the hepatic artery. Urgent revascularization or retransplantation may be required.

Question 46Perioperative and immediate postoperative care of the liver transplant recipient

During the anhepatic phase of liver transplantation, ionized calcium falls progressively despite stable blood pressure and oxygenation. Which mechanism best explains this?

  1. Citrate in transfused blood products Correct answer.
  2. Increased renal calcium excretion from furosemide
  3. Reperfusion washout of preservation solution
  4. Hyperventilation-induced respiratory alkalosis

Explanation

Citrate in stored blood products chelates ionized calcium, and the liver normally clears citrate; with the organ removed from the circuit, citrate accumulates and hypocalcemia deepens. Calcium chloride or gluconate is given during this phase to maintain myocardial contractility and vascular tone.

Question 47Perioperative and immediate postoperative care of the liver transplant recipient

Which nutritional approach is recommended in the first 24 to 48 hours after uncomplicated liver transplantation?

  1. Early enteral feeding within 24 hours Correct answer.
  2. Clear liquids only for 7 days
  3. Total parenteral nutrition until bowel sounds return
  4. Nothing by mouth until the first liver biopsy

Explanation

Enteral nutrition started within 24 to 48 hours is well tolerated, supports gut mucosal integrity, and reduces infectious complications compared with prolonged fasting. Parenteral nutrition is reserved for prolonged ileus, intestinal failure, or other contraindications to enteral feeding.

Question 48Perioperative and immediate postoperative care of the liver transplant recipient

Which donor-recipient cytomegalovirus serostatus carries the highest risk of post-transplant cytomegalovirus disease?

  1. Donor positive, recipient negative Correct answer.
  2. Donor negative, recipient positive
  3. Donor negative, recipient negative
  4. Donor positive, recipient positive

Explanation

The donor-positive, recipient-negative combination carries the highest risk because latently infected donor leukocytes are introduced into a host with no pre-existing immunity. These patients typically receive prolonged valganciclovir prophylaxis with or without preemptive viral monitoring.

Question 49Perioperative and immediate postoperative care of the liver transplant recipient

A living donor right lobe graft weighs 380 g and the recipient weighs 70 kg. Which complication is this recipient at highest risk of?

  1. Biliary cast syndrome
  2. Hepatic artery steal from a large spleen
  3. Portal vein thrombosis from low graft inflow
  4. Small-for-size syndrome Correct answer.

Explanation

The graft-to-recipient weight ratio here is about 0.54%, well below the usual 0.8% threshold, so the graft receives excessive portal inflow relative to its parenchymal mass. Small-for-size syndrome manifests with prolonged hyperbilirubinemia, coagulopathy, and refractory ascites, and it may require inflow modulation such as splenic artery embolization or portocaval shunting.

Question 50Perioperative and immediate postoperative care of the liver transplant recipient

Which laboratory pattern on postoperative day 7 meets published criteria for early allograft dysfunction?

  1. Bilirubin 8 mg/dL and INR 1.5 on day 7
  2. Bilirubin 4 mg/dL and INR 1.3 on day 7
  3. Bilirubin 6 mg/dL and INR 1.2 on day 7
  4. Bilirubin 12 mg/dL and INR 1.9 on day 7 Correct answer.

Explanation

Early allograft dysfunction is defined by any one of bilirubin of at least 10 mg/dL on day 7, INR of at least 1.6 on day 7, or aminotransferase peaks above 2000 U/L within the first 7 days. Its presence predicts graft loss and mortality and prompts evaluation for vascular, immunologic, and preservation-related causes.