I85PREP
⌘ K
ABTC CCTN study materials
ABTC CCTN study resources

ABTC CCTN practice questions

One question at a time. Build your ABTC CCTN understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Clinical Management of the Transplant Patient

A kidney transplant recipient is started on tacrolimus, mycophenolate, and prednisone. Which agent primarily prevents T-cell activation by inhibiting calcineurin?

  1. Basiliximab
  2. Prednisone
  3. Tacrolimus Correct answer.
  4. Mycophenolate mofetil

Explanation

Calcineurin inhibitors (tacrolimus, cyclosporine) block calcineurin, preventing dephosphorylation of NFAT and thereby reducing IL-2 transcription and T-cell activation. Mycophenolate inhibits IMPDH and lymphocyte proliferation, while steroids have broad anti-inflammatory effects. Basiliximab targets the CD25 chain of the IL-2 receptor.

Question 2Clinical Management of the Transplant Patient

Which finding most strongly suggests acute cellular rejection in a kidney allograft biopsy?

  1. Interstitial inflammation with tubulitis Correct answer.
  2. Mesangial matrix expansion
  3. Linear C4d deposition in peritubular capillaries
  4. Global glomerulosclerosis

Explanation

Acute T-cell-mediated (cellular) rejection is characterized by interstitial lymphocytic infiltrate with tubulitis and, in more severe grades, endarteritis. C4d deposition in peritubular capillaries is the hallmark of antibody-mediated rejection. Chronic changes such as glomerulosclerosis and matrix expansion reflect long-term injury.

Question 3Clinical Management of the Transplant Patient

A liver transplant recipient develops fever, right upper quadrant pain, and rising transaminases on postoperative day 6. What is the most appropriate initial step?

  1. Obtain Doppler ultrasound of the hepatic vasculature and biopsy Correct answer.
  2. Schedule elective cholangiography in one week
  3. Increase mycophenolate dose empirically
  4. Start empiric antiviral therapy for CMV

Explanation

Early post-transplant hepatic dysfunction with fever and RUQ pain raises concern for vascular complications (hepatic artery thrombosis), biliary problems, or acute rejection. Doppler ultrasound and biopsy are essential to distinguish these before adjusting immunosuppression. Empiric changes without diagnosis risk worsening infection or rejection.

Question 4Clinical Management of the Transplant Patient

Which prophylactic strategy is standard to reduce the risk of Pneumocystis jirovecii pneumonia after solid organ transplantation?

  1. Lifelong acyclovir monotherapy
  2. Routine monthly IVIG infusions
  3. Daily inhaled amphotericin B
  4. Trimethoprim-sulfamethoxazole for a defined postoperative period Correct answer.

Explanation

Trimethoprim-sulfamethoxazole is first-line prophylaxis against Pneumocystis jirovecii for a defined period after transplant, typically at least 6 to 12 months and longer with ongoing intensive immunosuppression. It also provides toxoplasma and some bacterial coverage. Alternatives include dapsone or atovaquone when sulfa is contraindicated.

Question 5Clinical Management of the Transplant Patient

A heart transplant recipient has a donor-specific antibody detected and develops new left ventricular dysfunction with capillary endothelial swelling on biopsy. Which process is most likely?

  1. Recurrent myocarditis
  2. Antibody-mediated rejection Correct answer.
  3. Calcineurin inhibitor toxicity
  4. Acute cellular rejection

Explanation

Donor-specific antibodies with graft dysfunction and microvascular injury (capillary swelling, macrophage infiltration, C4d positivity) indicate antibody-mediated rejection. Treatment includes plasmapheresis, IVIG, and often rituximab or bortezomib. Cellular rejection instead shows lymphocytic infiltrates with myocyte damage.

Question 6Clinical Management of the Transplant Patient

Which laboratory parameter is used to guide dosing of mycophenolate in many transplant programs?

  1. Serum beta-2 microglobulin
  2. Cyclosporine peak level
  3. Tacrolimus trough level
  4. Mycophenolic acid AUC or trough level Correct answer.

Explanation

Mycophenolic acid exposure, often estimated by limited sampling AUC or trough concentrations, can guide dose adjustment, especially with concomitant tacrolimus or in patients at risk for rejection or toxicity. Tacrolimus and cyclosporine levels guide their own dosing. Beta-2 microglobulin is not used for mycophenolate dosing.

Question 7Clinical Management of the Transplant Patient

A lung transplant recipient has declining FEV1 with no infection identified and biopsy showing lymphocytic bronchiolitis. What is the most likely diagnosis?

  1. Anastomotic dehiscence
  2. Primary graft dysfunction
  3. Pulmonary embolism
  4. Chronic lung allograft dysfunction Correct answer.

Explanation

Progressive FEV1 decline with biopsy evidence of lymphocytic bronchiolitis and no alternative cause indicates chronic lung allograft dysfunction, often manifesting as bronchiolitis obliterans syndrome. Primary graft dysfunction occurs in the immediate postoperative period. Anastomotic and vascular complications present differently.

Question 8Clinical Management of the Transplant Patient

Which infection is most classically associated with the use of belatacept in transplant recipients?

  1. Post-transplant lymphoproliferative disorder related to EBV Correct answer.
  2. Invasive aspergillosis
  3. Strongyloides hyperinfection
  4. Hepatitis C reactivation

Explanation

Belatacept, a costimulation blocker, has been associated with an increased risk of post-transplant lymphoproliferative disorder, particularly in EBV-seronegative recipients. EBV serostatus should be assessed before use. The other infections are not specifically linked to belatacept.

Question 9Clinical Management of the Transplant Patient

A pancreas transplant recipient has a sudden rise in serum amylase and lipase with abdominal pain and hyperglycemia. What is the most appropriate initial evaluation?

  1. Discontinuation of all immunosuppression
  2. Cross-sectional imaging to assess graft perfusion and rule out thrombosis Correct answer.
  3. Oral glucose tolerance testing
  4. Immediate increase in steroid dose

Explanation

Sudden graft dysfunction in a pancreas recipient raises concern for vascular thrombosis, which can rapidly lead to graft loss. Cross-sectional imaging with contrast assesses graft perfusion and vascular patency. Empiric immunosuppression changes or stopping therapy without diagnosis is inappropriate.

Question 10Clinical Management of the Transplant Patient

Which vaccination approach is recommended for transplant candidates before transplantation?

  1. Rely on post-transplant herd immunity alone
  2. Complete recommended immunizations before transplant when feasible Correct answer.
  3. Defer all vaccines until one year after transplant
  4. Use only live attenuated vaccines before surgery

Explanation

Pre-transplant immunization is preferred because immune responses are generally better before immunosuppression begins. Live vaccines are contraindicated after transplant and timing must be coordinated before surgery. Post-transplant response to vaccines is often diminished.

Question 11Clinical Management of the Transplant Patient

A kidney recipient on tacrolimus has a trough of 22 ng/mL, new tremor, and rising creatinine. What is the most appropriate management?

  1. Start high-dose corticosteroids for presumed rejection
  2. Add a second calcineurin inhibitor
  3. Reduce the tacrolimus dose and reassess renal function Correct answer.
  4. Increase the tacrolimus dose to prevent rejection

Explanation

Supratherapeutic tacrolimus levels with tremor and rising creatinine indicate calcineurin inhibitor toxicity. The appropriate action is dose reduction with close monitoring of levels and renal function. Increasing exposure or adding another calcineurin inhibitor would worsen toxicity.

Question 12Clinical Management of the Transplant Patient

Which finding is characteristic of BK polyomavirus nephropathy in a kidney transplant recipient?

  1. Positive donor-specific antibody with C4d deposition
  2. Sterile pyuria with negative cultures
  3. Decoy cells in urine with rising creatinine and high BK viral load Correct answer.
  4. Eosinophiluria with rash

Explanation

BK virus nephropathy presents with rising creatinine, high plasma BK viral load, and urinary decoy cells reflecting viruria. Diagnosis is confirmed by biopsy showing viral cytopathic changes. Reduction of immunosuppression is the cornerstone of management.

Question 13Clinical Management of the Transplant Patient

A liver transplant recipient with a positive crossmatch and high donor-specific antibodies is at greatest risk for which complication?

  1. Chronic hepatitis B flare
  2. Biliary cast syndrome
  3. Hepatic steatosis
  4. Acute antibody-mediated rejection Correct answer.

Explanation

Preformed donor-specific antibodies in a sensitized recipient increase the risk of acute antibody-mediated rejection, which can cause early graft dysfunction. Monitoring and tailored immunosuppression or desensitization may be used. The other listed conditions are unrelated to crossmatch status.

Question 14Clinical Management of the Transplant Patient

What is the primary purpose of induction therapy at the time of transplantation?

  1. To eliminate the need for maintenance therapy
  2. To treat established chronic rejection
  3. To prevent surgical site infection
  4. To reduce early acute rejection risk during initial immunosuppression Correct answer.

Explanation

Induction therapy provides intense early immunosuppression to reduce the incidence of acute rejection while maintenance therapy is established. It does not eliminate the need for maintenance immunosuppression. Established chronic rejection and infection prevention are managed differently.

Question 15Clinical Management of the Transplant Patient

A kidney transplant recipient develops new-onset diabetes after transplantation. Which immunosuppressant is most strongly associated with this complication?

  1. Basiliximab
  2. Azathioprine
  3. Mycophenolate mofetil
  4. Tacrolimus Correct answer.

Explanation

Tacrolimus, and to a lesser extent cyclosporine, is associated with post-transplant diabetes mellitus through impaired insulin secretion. Corticosteroids also contribute through insulin resistance. Mycophenolate, azathioprine, and basiliximab are not strongly diabetogenic.

Question 16Clinical Management of the Transplant Patient

Which parameter is most useful for monitoring graft function in a kidney transplant recipient during the early postoperative period?

  1. Serum alpha-fetoprotein
  2. Serum troponin
  3. Serial serum creatinine and urine output Correct answer.
  4. Serum amylase

Explanation

Serial serum creatinine and urine output are the primary markers of renal allograft function in the early postoperative period. A rise in creatinine or fall in urine output prompts evaluation for rejection, obstruction, or vascular issues. The other markers reflect different organs.

Question 17Clinical Management of the Transplant Patient

A heart transplant recipient is found to have moderate acute cellular rejection on surveillance biopsy. Which treatment is most appropriate?

  1. Antibiotic therapy alone
  2. High-dose corticosteroids with adjustment of maintenance immunosuppression Correct answer.
  3. Immediate retransplantation
  4. Reduction of all immunosuppression

Explanation

Moderate acute cellular rejection in a heart recipient is typically treated with high-dose corticosteroids and optimization of maintenance immunosuppression, with cytolytic therapy reserved for severe or refractory cases. Retransplantation is a last resort. Reducing immunosuppression would worsen rejection.

Question 18Clinical Management of the Transplant Patient

Which agent is used for prophylaxis against cytomegalovirus in a CMV-seronegative recipient of a CMV-seropositive organ?

  1. Trimethoprim-sulfamethoxazole
  2. Valganciclovir Correct answer.
  3. Fluconazole
  4. Isoniazid

Explanation

High-risk CMV mismatch (D+/R-) recipients receive antiviral prophylaxis, typically valganciclovir, for a defined period, sometimes with CMV immunoglobulin in selected settings. Fluconazole is antifungal, trimethoprim-sulfamethoxazole targets Pneumocystis and bacteria, and isoniazid treats tuberculosis.

Question 19Clinical Management of the Transplant Patient

A transplant recipient on tacrolimus develops new seizures and cortical blindness. Which diagnosis should be considered first?

  1. Acute cellular rejection
  2. Hepatic encephalopathy
  3. Posterior reversible encephalopathy syndrome Correct answer.
  4. Bacterial meningitis

Explanation

Posterior reversible encephalopathy syndrome is associated with calcineurin inhibitors such as tacrolimus and presents with seizures, headache, visual changes, and posterior white matter edema on imaging. Management includes reducing or stopping the offending agent. The other diagnoses do not fit this classic presentation.

Question 20Clinical Management of the Transplant Patient

Which factor most increases the risk of delayed graft function in a deceased-donor kidney transplant?

  1. Recipient female sex
  2. ABO compatibility
  3. Living-donor status
  4. Prolonged cold ischemia time Correct answer.

Explanation

Prolonged cold ischemia time increases ischemic injury and the likelihood of delayed graft function. Other donor factors include donation after circulatory death and advanced donor age. ABO compatibility and living-donor status reduce rather than increase this risk.

Question 21Clinical Management of the Transplant Patient

A liver transplant recipient is found to have a rising tacrolimus level and new renal dysfunction while on fluconazole. What is the most likely explanation?

  1. Allergic reaction to tacrolimus
  2. Hepatic artery thrombosis
  3. Cytochrome P450 induction decreasing tacrolimus exposure
  4. Cytochrome P450 inhibition increasing tacrolimus exposure Correct answer.

Explanation

Azole antifungals such as fluconazole inhibit CYP3A4, reducing tacrolimus metabolism and raising blood levels, which can cause nephrotoxicity. Dose reduction and close monitoring of tacrolimus levels are required. Inducers such as rifampin would lower levels.

Question 22Clinical Management of the Transplant Patient

Which clinical sign suggests a lymphocele compressing the graft after kidney transplantation?

  1. Declining urine output with ipsilateral leg swelling Correct answer.
  2. Fever with purulent wound drainage
  3. New systolic murmur
  4. Sudden anuria with hyperkalemia

Explanation

A lymphocele can compress the ureter or iliac vein, producing declining urine output, hydronephrosis, and ipsilateral leg edema. Diagnosis is by ultrasound. Purulent drainage suggests infection and a murmur suggests cardiac pathology.

Question 23Clinical Management of the Transplant Patient

A transplant recipient with a history of latent tuberculosis has a positive interferon-gamma release assay before transplant. What is the recommended management?

  1. Treat latent tuberculosis before or around transplantation Correct answer.
  2. Delay all immunosuppression indefinitely
  3. Start broad-spectrum antibiotics
  4. No action because the assay is often false positive

Explanation

Latent tuberculosis in transplant candidates should be treated, typically with isoniazid or a rifamycin-based regimen, because immunosuppression increases the risk of reactivation. Treatment timing is coordinated with transplant to manage drug interactions. Ignoring a positive assay risks post-transplant reactivation.

Question 24Clinical Management of the Transplant Patient

Which complication is most associated with sirolimus use early after kidney transplantation?

  1. Severe hypertension and gingival hyperplasia
  2. Hemolytic uremic syndrome
  3. Impaired wound healing and lymphocele formation Correct answer.
  4. Acute interstitial nephritis

Explanation

Mammalian target of rapamycin inhibitors such as sirolimus impair wound healing and increase the risk of lymphoceles and wound dehiscence, especially when used early after surgery. They are often avoided in the immediate postoperative period for this reason. Hypertension with gingival hyperplasia is more typical of cyclosporine.

Question 25Clinical Management of the Transplant Patient

What is the main rationale for using corticosteroid-sparing regimens in maintenance immunosuppression?

  1. To increase the risk of rejection intentionally
  2. To replace calcineurin inhibitors entirely
  3. To reduce cumulative metabolic and infectious complications Correct answer.
  4. To eliminate the need for any monitoring

Explanation

Steroid-sparing or withdrawal protocols aim to reduce long-term complications such as diabetes, osteoporosis, weight gain, and infection while maintaining adequate immunosuppression. Patients require careful monitoring for rejection after withdrawal. These regimens do not eliminate monitoring or necessarily replace calcineurin inhibitors.

Question 26Clinical Management of the Transplant Patient

A kidney transplant recipient is prescribed a prolonged course of a strong CYP3A4 inhibitor for a fungal infection. Which change in tacrolimus management is most appropriate?

  1. Double the tacrolimus dose empirically
  2. Add a second calcineurin inhibitor for coverage
  3. Reduce the tacrolimus dose and monitor trough levels closely Correct answer.
  4. Stop tacrolimus permanently

Explanation

Strong CYP3A4 inhibitors decrease tacrolimus metabolism, raising blood concentrations and toxicity risk. The standard response is preemptive dose reduction with frequent trough monitoring and adjustment.

Question 27Clinical Management of the Transplant Patient

Which finding on urinalysis most directly suggests a urinary tract infection rather than rejection in a kidney transplant recipient?

  1. Isolated microscopic hematuria
  2. Sterile pyuria with proteinuria
  3. Broad waxy casts
  4. Pyuria with positive nitrite and leukocyte esterase Correct answer.

Explanation

Nitrite positivity reflects nitrate-reducing bacteria, and leukocyte esterase indicates pyuria, together supporting bacterial urinary tract infection. Rejection more often produces proteinuria and rising creatinine without bacteriuria markers.

Question 28Clinical Management of the Transplant Patient

What is the primary rationale for using a steroid-free maintenance regimen in selected transplant recipients?

  1. To eliminate the need for any other immunosuppression
  2. To guarantee freedom from acute rejection
  3. To reduce cumulative metabolic and infectious complications of long-term steroids Correct answer.
  4. To reverse established chronic allograft injury

Explanation

Steroid avoidance aims to limit cumulative adverse effects such as diabetes, hypertension, weight gain, and infection while preserving adequate immunosuppression with other agents. It does not remove the need for maintenance therapy or abolish rejection risk.

Question 29Clinical Management of the Transplant Patient

A kidney transplant recipient develops fever, hypoxemia, and diffuse bilateral interstitial infiltrates in the second month after transplant. Which pathogen should be prioritized in the differential?

  1. Pneumocystis jirovecii Correct answer.
  2. Epstein-Barr virus
  3. Clostridioides difficile
  4. Hepatitis C virus

Explanation

Pneumocystis pneumonia classically presents in the second to sixth month after transplant with fever, hypoxemia, and bilateral interstitial infiltrates in patients on immunosuppression. Prophylaxis with trimethoprim-sulfamethoxazole is standard during this high-risk period.

Question 30Clinical Management of the Transplant Patient

A liver transplant recipient has a bile leak from the anastomosis with fever and rising bilirubin. Which initial management step is most appropriate?

  1. Increase immunosuppression to protect the graft
  2. Observation alone with repeat labs in one week
  3. Immediate re-transplantation
  4. Biliary drainage with antibiotics and surgical or endoscopic repair planning Correct answer.

Explanation

Bile leaks cause chemical and infectious peritonitis and threaten the biliary anastomosis, so drainage and antibiotic therapy with definitive repair are required. Delay risks sepsis and graft loss.

Question 31Clinical Management of the Transplant Patient

Which monitoring strategy is recommended for detecting hepatic artery thrombosis after liver transplantation?

  1. Annual bone density scanning
  2. Monthly colonoscopy
  3. Serial liver enzymes plus Doppler ultrasound of the hepatic artery Correct answer.
  4. Routine serum amylase measurement

Explanation

Hepatic artery thrombosis presents with rising transaminases, fever, and biliary injury, and Doppler ultrasound is the first-line imaging to assess arterial flow. Early detection is critical because it threatens graft viability.

Question 32Clinical Management of the Transplant Patient

A heart transplant recipient develops new bradyarrhythmia and low cardiac output in the first week after transplant. Which cause should be considered?

  1. Acute rejection or graft dysfunction requiring urgent evaluation Correct answer.
  2. Chronic allograft vasculopathy
  3. Late post-transplant lymphoproliferative disorder
  4. Osteoporosis of the sternum

Explanation

Early hemodynamic deterioration after heart transplant is most often due to acute rejection or primary graft dysfunction and requires urgent biopsy and echocardiographic evaluation. Chronic vasculopathy and lymphoproliferative disease occur much later.

Question 33Clinical Management of the Transplant Patient

Which intervention most reduces the risk of cytomegalovirus disease in a CMV-seronegative kidney recipient of a seropositive donor?

  1. Antiviral prophylaxis or preemptive monitoring for a defined period Correct answer.
  2. Reducing all immunosuppression to zero
  3. Immediate vaccination with live attenuated CMV vaccine
  4. Routine administration of intravenous immunoglobulin alone

Explanation

The highest-risk CMV mismatch benefits from antiviral prophylaxis or preemptive viral monitoring according to program protocol. Live vaccines are contraindicated in immunosuppressed recipients.

Question 34Clinical Management of the Transplant Patient

A kidney transplant recipient has a creatinine that rises over 48 hours with decreased urine output and a tacrolimus trough within target range. Which next step best distinguishes rejection from other causes?

  1. Repeat creatinine in two weeks
  2. Ultrasound of the native kidneys
  3. Empiric pulse steroids without further testing
  4. Allograft biopsy with histologic and immunohistochemical evaluation Correct answer.

Explanation

Biopsy remains the reference standard to differentiate acute cellular rejection, antibody-mediated rejection, drug toxicity, and infection when the clinical picture is ambiguous. Empiric treatment without diagnosis risks inappropriate immunosuppression.

Question 35Clinical Management of the Transplant Patient

Which clinical scenario most strongly suggests antibody-mediated rejection in a kidney transplant recipient?

  1. Rising creatinine with tacrolimus trough above target
  2. Rising creatinine with hypovolemia after diuresis
  3. Rising creatinine with pyuria and positive urine culture
  4. Rising creatinine with donor-specific antibodies and peritubular capillaritis on biopsy Correct answer.

Explanation

Antibody-mediated rejection is defined by donor-specific antibody detection plus microvascular inflammation such as peritubular capillaritis and C4d deposition. Infection, drug toxicity, and prerenal states cause dysfunction without these immunologic features.

Question 36Clinical Management of the Transplant Patient

Which dietary instruction is appropriate for a kidney transplant recipient with hyperkalemia and stable graft function?

  1. Increase potassium-rich foods to improve cardiac function
  2. Restrict all protein intake indefinitely
  3. Limit high-potassium foods and review medications that raise potassium Correct answer.
  4. Liberalize salt intake to improve perfusion

Explanation

Hyperkalemia in transplant recipients is managed by limiting dietary potassium and reviewing contributors such as tacrolimus, trimethoprim, and renin-angiotensin blockade. Unrestricted potassium intake risks arrhythmia.

Question 37Clinical Management of the Transplant Patient

A lung transplant recipient develops progressive dyspnea with declining spirometry and biopsy showing organizing pneumonia without infection. Which process is most likely?

  1. Native lung hyperinflation
  2. Pulmonary embolism
  3. Chronic lung allograft dysfunction Correct answer.
  4. Antibody-mediated hyperacute rejection

Explanation

Chronic lung allograft dysfunction encompasses restrictive and obstructive phenotypes with histologic patterns such as organizing pneumonia and bronchiolitis obliterans in the absence of infection. It is the leading cause of late graft loss after lung transplant.

Question 38Clinical Management of the Transplant Patient

Which laboratory abnormality is most characteristic of tacrolimus toxicity in a transplant recipient?

  1. Isolated eosinophilia
  2. Hypercalcemia with nephrolithiasis
  3. Low white blood cell count with mouth ulcers
  4. Elevated creatinine with tremor and hyperkalemia Correct answer.

Explanation

Calcineurin inhibitor toxicity produces nephrotoxicity with rising creatinine, tremor, hyperkalemia, and hypomagnesemia. These findings should prompt trough review and dose adjustment.

Question 39Clinical Management of the Transplant Patient

A pancreas-kidney transplant recipient develops hematuria and a falling hematocrit with abdominal pain. Which complication should be suspected?

  1. Acute cellular rejection of the kidney
  2. Bladder anastomotic bleeding or graft-site hemorrhage Correct answer.
  3. Hyperkalemia from tacrolimus
  4. Chronic allograft nephropathy

Explanation

Hematuria with dropping hematocrit after pancreas transplantation suggests bleeding at the anastomosis or graft site and warrants urgent imaging and surgical evaluation. Rejection and chronic nephropathy do not typically present with acute hemorrhage.

Question 40Clinical Management of the Transplant Patient

What is the main purpose of therapeutic drug monitoring for tacrolimus?

  1. To measure renal function directly
  2. To confirm patient adherence only
  3. To maintain concentrations within a range that balances rejection and toxicity risk Correct answer.
  4. To determine the appropriate vaccination schedule

Explanation

Tacrolimus has a narrow therapeutic index with substantial interpatient variability, so trough monitoring keeps exposure in a range that limits rejection while avoiding nephrotoxicity and neurotoxicity. Adherence assessment is a secondary benefit rather than the primary purpose.

Question 41Clinical Management of the Transplant Patient

A liver transplant recipient develops confusion, asterixis, and rising ammonia with a patent hepatic artery and normal tacrolimus level. Which cause should be evaluated first?

  1. Mycophenolate overdose
  2. Acute cellular rejection of the kidney
  3. Hypercalcemia
  4. Graft dysfunction or portal vein complication Correct answer.

Explanation

Encephalopathy with hyperammonemia after liver transplant points to hepatic dysfunction or a vascular complication impairing portal flow, requiring urgent imaging and graft assessment. Normal tacrolimus levels and arterial patency do not exclude portal or parenchymal problems.

Question 42Clinical Management of the Transplant Patient

Which preventive measure is recommended to reduce the risk of post-transplant osteoporosis in long-term steroid recipients?

  1. Calcium and vitamin D supplementation with bone density monitoring Correct answer.
  2. Routine bisphosphonate therapy for all patients without assessment
  3. High-dose vitamin A supplementation
  4. Immobilization to reduce bone stress

Explanation

Steroid-induced bone loss is managed with calcium and vitamin D, lifestyle measures, and periodic bone density assessment to guide additional therapy. Universal bisphosphonate use without evaluation is not recommended.

Question 43Clinical Management of the Transplant Patient

A kidney transplant recipient reports adherence difficulties with a twice-daily immunosuppressant regimen. Which strategy is most appropriate?

  1. Double the dose on missed days
  2. Explore once-daily formulations and simplify the regimen with the care team Correct answer.
  3. Substitute an herbal supplement
  4. Discontinue the medication until adherence improves

Explanation

Simplifying dosing, using once-daily formulations where available, and engaging the patient in adherence support reduce the risk of rejection from missed doses. Abrupt discontinuation or unverified supplements risk graft loss and interactions.

Question 44Clinical Management of the Transplant Patient

Which finding should raise concern for post-transplant lymphoproliferative disorder in a transplant recipient?

  1. Sudden hyperglycemia with abdominal pain
  2. Painless hematuria with sterile urine
  3. Tremor with elevated tacrolimus level
  4. Painless enlarging lymph nodes with fever and rising EBV viral load Correct answer.

Explanation

Post-transplant lymphoproliferative disorder often presents with lymphadenopathy, fever, and rising Epstein-Barr viral load in immunosuppressed patients, especially after intensified therapy. Tissue diagnosis is required to confirm the diagnosis.

Question 45Clinical Management of the Transplant Patient

A heart transplant recipient with a history of coronary disease has new wall motion abnormalities and negative donor-specific antibodies. Which diagnosis should be considered?

  1. Acute bacterial pericarditis
  2. Cardiac allograft vasculopathy Correct answer.
  3. Pulmonary hypertension
  4. Sternal wound dehiscence

Explanation

Cardiac allograft vasculopathy is a chronic immune and nonimmune process causing diffuse coronary intimal thickening, regional wall motion abnormalities, and heart failure. It can occur without circulating donor-specific antibodies.

Question 46Clinical Management of the Transplant Patient

Which patient instruction best reduces infection risk after transplantation?

  1. Share food and utensils with household members
  2. Delay all vaccinations indefinitely
  3. Practice hand hygiene and avoid contact with people who have active infections Correct answer.
  4. Stop prophylactic antibiotics once feeling well

Explanation

Hand hygiene and avoidance of known infectious contacts are cornerstone behavioral measures for immunosuppressed patients. Prophylaxis should continue per protocol, and inactivated vaccines should be kept current.

Question 47Clinical Management of the Transplant Patient

A kidney transplant recipient has new-onset tremor, headache, and blood pressure elevation with normal tacrolimus levels. Which evaluation is most appropriate?

  1. Increase tacrolimus dose
  2. Start a live vaccine series
  3. Restrict all fluids
  4. Assess for hypertensive urgency and neurologic complications Correct answer.

Explanation

Headache with tremor and elevated blood pressure may reflect hypertensive emergency or calcineurin-related neurotoxicity even with normal levels, so urgent blood pressure assessment and neurologic evaluation are needed. Increasing immunosuppression would be inappropriate.

Question 48Clinical Management of the Transplant Patient

Which factor most influences the choice of induction agent in a kidney transplant recipient with a history of prior sensitization?

  1. Time of day of surgery
  2. Immunologic risk including panel-reactive antibody and donor-specific antibody status Correct answer.
  3. Donor's blood type alone
  4. Patient's hair color

Explanation

Induction selection is driven by immunologic risk, with sensitized patients or those with donor-specific antibodies often receiving lymphocyte-depleting agents. Lower-risk patients may receive non-depleting induction.

Question 49Clinical Management of the Transplant Patient

Which monitoring is most appropriate for a transplant recipient starting an mTOR inhibitor such as sirolimus?

  1. Periodic lipid panel and proteinuria assessment Correct answer.
  2. Daily electrocardiogram
  3. Weekly colonoscopy
  4. Monthly bone marrow biopsy

Explanation

mTOR inhibitors cause hyperlipidemia and can worsen proteinuria, so lipid monitoring and urine protein assessment are recommended. These effects guide dose adjustment and cardiovascular risk management.

Question 50Clinical Management of the Transplant Patient

A liver transplant recipient is scheduled for elective surgery and is on chronic immunosuppression. Which perioperative consideration is most important?

  1. Maintain immunosuppression and coordinate stress-dose steroid coverage Correct answer.
  2. Withhold antibiotics to avoid interactions
  3. Discontinue all immunosuppression for two weeks
  4. Avoid monitoring drug levels during hospitalization

Explanation

Continuity of immunosuppression prevents rejection, and patients on chronic corticosteroids may need perioperative stress dosing. Drug levels should continue to be monitored because absorption and clearance may change.