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BCTXP practice questions

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Question 1Clinical Foundations and Transplant Immunology

Which HLA class I molecule presents endogenous peptides to CD8+ T cells?

  1. HLA-DP
  2. HLA-DR
  3. HLA-DQ
  4. HLA-A Correct answer.

Explanation

HLA-A, HLA-B, and HLA-C are class I molecules that display endogenous peptides on the cell surface for recognition by CD8+ cytotoxic T cells. The class II molecules HLA-DR, HLA-DP, and HLA-DQ present exogenous peptides to CD4+ T cells instead.

Question 2Clinical Foundations and Transplant Immunology

A patient awaiting transplant has preformed donor-specific antibodies detected by single-antigen bead assay. What is the most likely consequence if the transplant proceeds?

  1. Delayed wound healing
  2. Hyperacute rejection Correct answer.
  3. Accelerated atherosclerosis
  4. Graft-versus-host disease

Explanation

Preformed donor-specific antibodies bind donor endothelium at the time of reperfusion, activating complement and causing rapid thrombotic injury known as hyperacute rejection. Screening and crossmatching are performed specifically to prevent this outcome.

Question 3Clinical Foundations and Transplant Immunology

Which immunosuppressant acts by inhibiting calcineurin and thereby blocking IL-2 transcription?

  1. Sirolimus
  2. Belatacept
  3. Tacrolimus Correct answer.
  4. Mycophenolate mofetil

Explanation

Tacrolimus binds FKBP-12 and inhibits calcineurin, preventing dephosphorylation of NFAT and blocking IL-2 gene transcription in T cells. Mycophenolate inhibits IMPDH, sirolimus inhibits mTOR, and belatacept blocks costimulation.

Question 4Clinical Foundations and Transplant Immunology

What is the primary function of the complement system in transplant immunology?

  1. Opsonization and membrane attack of antibody-coated cells Correct answer.
  2. Direct antigen presentation to T cells
  3. Class switching of B cells to IgG
  4. Production of donor-specific antibodies

Explanation

Complement proteins opsonize targets, recruit inflammatory cells, and assemble the membrane attack complex to lyse antibody-coated cells. This cascade is central to antibody-mediated rejection of a graft.

Question 5Clinical Foundations and Transplant Immunology

Which cell type is the principal professional antigen-presenting cell that primes naive T cells in the allograft response?

  1. Neutrophil
  2. Platelet
  3. Erythrocyte
  4. Dendritic cell Correct answer.

Explanation

Dendritic cells capture, process, and present alloantigen with costimulatory signals required to prime naive T cells. They are the most potent antigen-presenting cells and are key initiators of rejection.

Question 6Clinical Foundations and Transplant Immunology

A kidney transplant recipient develops rising creatinine and donor-specific antibodies six days after transplant. Which rejection category fits this timing?

  1. Chronic rejection
  2. Recurrent primary disease
  3. Hyperacute rejection
  4. Acute antibody-mediated rejection Correct answer.

Explanation

Antibody-mediated rejection occurring days to weeks after transplant, with donor-specific antibodies and graft dysfunction, is classified as acute antibody-mediated rejection. Hyperacute rejection would occur within minutes to hours, and chronic changes develop over months to years.

Question 7Clinical Foundations and Transplant Immunology

Which HLA matching consideration is most important for minimizing rejection in kidney transplantation?

  1. Matching donor and recipient eye color
  2. Matching donor and recipient age
  3. Matching donor and recipient height
  4. Matching donor and recipient ABO blood type Correct answer.

Explanation

ABO compatibility is a fundamental requirement because preformed isohemagglutinins can cause immediate graft injury. HLA matching further reduces rejection risk, but ABO compatibility is the baseline prerequisite.

Question 8Clinical Foundations and Transplant Immunology

What is the role of the thymus in transplant immunology?

  1. It secretes complement proteins
  2. It stores mature erythrocytes
  3. It produces insulin for glucose control
  4. It provides negative selection of self-reactive T cells Correct answer.

Explanation

The thymus supports T cell maturation, including negative selection that deletes T cells strongly reactive to self-antigens. This central tolerance mechanism shapes the repertoire that later encounters alloantigen.

Question 9Clinical Foundations and Transplant Immunology

A recipient of a living-donor kidney transplant is being evaluated for immunosuppressive therapy. Why is a calcineurin inhibitor often combined with an antiproliferative agent?

  1. To replace the need for HLA matching
  2. To eliminate the need for any monitoring
  3. To increase the risk of infection
  4. To allow lower doses of each drug and reduce toxicity Correct answer.

Explanation

Combining agents with different mechanisms allows dose reduction of each, limiting dose-dependent toxicities such as nephrotoxicity and myelosuppression. The combination targets distinct steps in T cell activation and proliferation for additive efficacy.

Question 10Clinical Foundations and Transplant Immunology

Which mechanism best describes how sirolimus suppresses T cell responses?

  1. Preventing MHC class II expression
  2. Inhibiting mTOR-dependent proliferation signals Correct answer.
  3. Depleting circulating T cells by lysis
  4. Blocking IL-2 receptor binding

Explanation

Sirolimus binds FKBP-12 and inhibits mTOR, blocking cytokine-driven proliferation and cell-cycle progression in T cells. It does not lyse T cells or block IL-2 receptor binding directly.

Question 11Clinical Foundations and Transplant Immunology

In a patient with a positive complement-dependent cytotoxicity crossmatch, what does the result indicate?

  1. The recipient has no preformed antibodies
  2. The donor and recipient are HLA-identical
  3. Donor lymphocytes are resistant to complement
  4. Recipient serum contains antibodies that lyse donor lymphocytes Correct answer.

Explanation

A positive CDC crossmatch means recipient serum contains antibodies that activate complement and lyse donor lymphocytes, indicating preformed donor reactivity. This generally contraindicates proceeding with the transplant.

Question 12Clinical Foundations and Transplant Immunology

Which process allows recipient T cells to recognize intact donor MHC molecules directly on donor antigen-presenting cells?

  1. Central tolerance
  2. Indirect allorecognition
  3. Semi-direct allorecognition
  4. Direct allorecognition Correct answer.

Explanation

Direct allorecognition occurs when recipient T cells engage intact donor MHC-peptide complexes on donor antigen-presenting cells. This pathway dominates early acute rejection, while indirect recognition involves recipient processing of donor peptides.

Question 13Clinical Foundations and Transplant Immunology

A transplant candidate has a calculated panel-reactive antibody of 95%. What does this value represent?

  1. The percentage of immunosuppression dose required
  2. The probability of acute cellular rejection
  3. The percentage of the general donor population to which the patient has antibodies Correct answer.
  4. The percentage of donor HLA alleles the patient shares

Explanation

The calculated panel-reactive antibody estimates the proportion of the potential donor pool that would be incompatible based on the patient's HLA antibodies. A high cPRA indicates broad sensitization and difficulty finding a compatible donor.

Question 14Clinical Foundations and Transplant Immunology

Which cytokine is the principal target of many induction strategies aimed at preventing T cell activation?

  1. Transforming growth factor beta
  2. Interleukin-2 Correct answer.
  3. Interferon-gamma
  4. Interleukin-8

Explanation

Interleukin-2 is a key T cell growth factor, and IL-2 receptor antagonists such as basiliximab are used for induction to blunt T cell proliferation. Blocking this axis reduces early rejection without broad lymphocyte depletion.

Question 15Clinical Foundations and Transplant Immunology

A patient with a history of multiple pregnancies is more likely to be sensitized because of which mechanism?

  1. Exposure to fetal paternal HLA antigens Correct answer.
  2. Reduced complement activity
  3. Decreased antibody class switching
  4. Increased thymic output of self-reactive T cells

Explanation

Pregnancy exposes the mother to paternal HLA antigens expressed on fetal cells, which can induce alloantibodies. This prior sensitization increases the risk of donor-specific antibodies in later transplants.

Question 16Clinical Foundations and Transplant Immunology

Which statement best describes the role of T regulatory cells in transplant tolerance?

  1. They suppress alloreactive effector T cell responses Correct answer.
  2. They activate complement on the graft surface
  3. They directly lyse allograft endothelial cells
  4. They produce donor-specific antibodies

Explanation

T regulatory cells suppress the activation and proliferation of alloreactive effector T cells through cytokine and contact-dependent mechanisms. Their expansion is associated with improved graft survival and tolerance induction strategies.

Question 17Clinical Foundations and Transplant Immunology

A kidney recipient with a stable graft develops BK virus nephropathy. What is the most appropriate initial management regarding immunosuppression?

  1. Discontinue all monitoring
  2. Reduce immunosuppression to allow immune clearance Correct answer.
  3. Add a second calcineurin inhibitor
  4. Increase immunosuppression to control inflammation

Explanation

BK virus nephropathy arises from excessive immunosuppression, so the mainstay of initial management is careful reduction of immunosuppression to permit immune control of the virus. Increasing immunosuppression would worsen viral replication and graft injury.

Question 18Clinical Foundations and Transplant Immunology

Which of the following best explains why ABO-incompatible kidney transplantation requires pretransplant antibody removal?

  1. To enhance T cell activation
  2. To remove isohemagglutinins that could injure the graft Correct answer.
  3. To increase donor HLA matching
  4. To stimulate complement production

Explanation

ABO-incompatible grafts are vulnerable to preformed isohemagglutinins that can cause immediate endothelial injury. Plasmapheresis or immunoadsorption lowers these antibody titers before reperfusion to permit safe transplantation.

Question 19Clinical Foundations and Transplant Immunology

Which histologic finding is characteristic of acute cellular rejection in a renal allograft?

  1. Arterial intimal fibrosis with duplication
  2. Mesangial IgA deposits
  3. Interstitial lymphocytic infiltrate with tubulitis Correct answer.
  4. Global glomerulosclerosis

Explanation

Acute cellular rejection is characterized by interstitial inflammation with lymphocytes invading tubules, known as tubulitis. This pattern reflects T cell-mediated injury to the graft parenchyma.

Question 20Clinical Foundations and Transplant Immunology

Which factor most strongly increases the immunologic risk of a transplant from an unrelated deceased donor?

  1. HLA mismatch between donor and recipient Correct answer.
  2. Recipient body mass index
  3. Donor blood type O
  4. Donor organ cold storage time

Explanation

Greater HLA mismatch increases the number of foreign epitopes recognized by the recipient immune system, raising rejection risk. Other factors may influence outcomes but are not primarily immunologic compatibility measures.

Question 21Clinical Foundations and Transplant Immunology

A patient is being considered for desensitization before transplant. Which approach is most consistent with this strategy?

  1. Reducing HLA typing frequency
  2. Plasmapheresis combined with intravenous immunoglobulin Correct answer.
  3. Increasing dietary protein intake
  4. Delaying crossmatch until after transplant

Explanation

Desensitization aims to lower donor-specific antibody levels, and plasmapheresis plus intravenous immunoglobulin is a recognized combination for this purpose. It reduces antibody burden before crossmatch and transplant.

Question 22Clinical Foundations and Transplant Immunology

Which mechanism underlies chronic allograft vasculopathy?

  1. Immediate IgE-mediated mast cell degranulation
  2. Immune-mediated intimal injury and smooth muscle proliferation Correct answer.
  3. Acute complement lysis of donor erythrocytes
  4. Bacterial colonization of the graft artery

Explanation

Chronic allograft vasculopathy results from repetitive immune and nonimmune endothelial injury leading to intimal smooth muscle proliferation and luminal narrowing. Antibody and T cell responses contribute to this progressive arterial disease.

Question 23Clinical Foundations and Transplant Immunology

Which statement best explains the concept of HLA epitope matching compared with whole-antigen matching?

  1. It eliminates the need for any HLA typing
  2. It matches only ABO antigens
  3. It measures complement activity directly
  4. It considers specific antibody-accessible amino acid configurations on HLA molecules Correct answer.

Explanation

Epitope matching evaluates the specific surface amino acid configurations that antibodies recognize, which can refine risk assessment beyond whole-antigen mismatch. This approach may improve prediction of donor-specific antibody formation.

Question 24Clinical Foundations and Transplant Immunology

What is the immunologic rationale for using intravenous immunoglobulin in highly sensitized transplant candidates?

  1. It blocks calcineurin phosphatase activity
  2. It increases MHC class I expression on the graft
  3. It directly lyses donor T cells
  4. It modulates antibody production and neutralizes circulating alloantibodies Correct answer.

Explanation

Intravenous immunoglobulin can neutralize circulating antibodies and modulate B cell and antibody responses, lowering sensitization. It is often combined with plasmapheresis in desensitization protocols.

Question 25Clinical Foundations and Transplant Immunology

A transplant recipient develops fever, rash, and diarrhea three weeks after transplant, and cytomegalovirus DNA is detected. Which immune mechanism most directly explains susceptibility to this infection?

  1. Reduced erythrocyte production
  2. Impaired T cell-mediated immunity from immunosuppression Correct answer.
  3. Loss of complement proteins
  4. Increased neutrophil count

Explanation

Cytomegalovirus control depends on intact T cell immunity, and immunosuppressive drugs impair T cell responses, allowing viral reactivation. This explains the timing of reactivation after transplant when immunosuppression is intense.

Question 26Clinical Foundations and Transplant Immunology

Which immunoglobulin class is responsible for the antibodies detected in a standard complement-dependent cytotoxicity crossmatch?

  1. IgM
  2. IgG Correct answer.
  3. IgE
  4. IgA

Explanation

The complement-dependent cytotoxicity crossmatch detects donor-reactive IgG antibodies in recipient serum. IgG alloantibodies fix complement and can cause hyperacute or accelerated rejection. IgM reactivity is generally considered less clinically significant in this assay.

Question 27Clinical Foundations and Transplant Immunology

A recipient's T cells respond to donor antigen-presenting cells presenting intact donor HLA molecules. Which pathway of allorecognition does this describe?

  1. Semidirect pathway
  2. Autologous pathway
  3. Indirect pathway
  4. Direct pathway Correct answer.

Explanation

Direct allorecognition occurs when recipient T cells engage intact donor HLA molecules displayed on the surface of donor antigen-presenting cells. This pathway dominates early after transplantation and drives acute cellular rejection. The indirect pathway instead involves recipient antigen-presenting cells presenting processed donor peptides.

Question 28Clinical Foundations and Transplant Immunology

A transplant candidate has donor-specific antibodies that are present but at low titer, and the flow cytometric crossmatch is positive while the complement-dependent cytotoxicity crossmatch is negative. Which interpretation is most appropriate?

  1. The positive flow crossmatch indicates clinically insignificant antibody and can be ignored
  2. The discrepancy indicates a laboratory error requiring repeat testing before any decision
  3. The flow crossmatch detects low-level IgG that may still confer increased rejection risk Correct answer.
  4. The negative cytotoxicity crossmatch excludes any risk of antibody-mediated rejection

Explanation

Flow cytometric crossmatch is more sensitive than cytotoxicity and can detect low-titer donor-specific IgG that does not fix enough complement to produce a positive cytotoxicity result. Such low-level antibodies may still increase the risk of antibody-mediated rejection and warrant risk assessment. The discordance is a recognized biological phenomenon rather than an error.

Question 29Clinical Foundations and Transplant Immunology

Which pair of HLA class II molecules is most relevant when evaluating donor-recipient compatibility for T cell-mediated responses?

  1. HLA-C and HLA-E
  2. HLA-G and HLA-F
  3. HLA-A and HLA-B
  4. HLA-DR and HLA-DQ Correct answer.

Explanation

HLA class II molecules, principally HLA-DR and HLA-DQ, present processed peptides to CD4-positive T helper cells and are central to donor-recipient compatibility assessment. Matching at these loci influences CD4 T cell activation and downstream alloimmune responses. HLA-A, HLA-B, and HLA-C are class I molecules recognized by CD8-positive T cells.

Question 30Clinical Foundations and Transplant Immunology

A recipient receives a kidney graft and later develops donor-specific antibodies directed against donor HLA class II antigens. Which cellular target is most directly affected by these antibodies?

  1. Donor endothelial and antigen-presenting cells expressing class II HLA Correct answer.
  2. Donor tubular epithelial cells lacking HLA expression
  3. Recipient erythrocytes expressing ABO antigens
  4. Recipient natural killer cells lacking Fc receptors

Explanation

HLA class II molecules are constitutively expressed on donor endothelial cells and antigen-presenting cells, making them direct targets of donor-specific class II antibodies. Antibody binding can activate complement and recruit effector cells, contributing to antibody-mediated rejection. Erythrocytes and HLA-negative tubular cells are not the principal class II targets.

Question 31Pre-Transplant Evaluation and Candidate Selection

A candidate for allogeneic hematopoietic cell transplant has a Karnofsky Performance Status of 60%. What does this score most directly indicate about the patient?

  1. The patient is able to carry on normal activity with effort and some symptoms
  2. The patient is completely disabled and cannot perform any self-care
  3. The patient requires considerable assistance and frequent medical care Correct answer.
  4. The patient is able to carry on normal activity with no evidence of disease

Explanation

Karnofsky scores range from 100 (normal, no complaints) to 0 (dead), with 60 reflecting a patient who requires considerable assistance and frequent medical care. Performance status informs whether the candidate can tolerate conditioning intensity. Lower scores generally predict worse transplant outcomes and influence regimen selection.

Question 32Pre-Transplant Evaluation and Candidate Selection

Which parameter is most important to assess when determining whether a patient with cardiac dysfunction can safely undergo myeloablative conditioning?

  1. Left ventricular ejection fraction Correct answer.
  2. Serum ferritin level
  3. Estimated glomerular filtration rate
  4. Pulmonary diffusion capacity

Explanation

Left ventricular ejection fraction is the standard measure of systolic cardiac reserve and is used to screen candidates before myeloablative conditioning, which imposes significant fluid and hemodynamic stress. A substantially reduced ejection fraction typically prompts reduced-intensity conditioning or exclusion. Other organ assessments are relevant but do not directly measure cardiac reserve.

Question 33Pre-Transplant Evaluation and Candidate Selection

A candidate has a documented history of hepatitis B virus infection. Which pre-transplant measure most reduces the risk of reactivation after transplant?

  1. Routine administration of intravenous immunoglobulin before transplant
  2. Pre-emptive splenectomy prior to conditioning
  3. Serial measurement of alpha-fetoprotein alone
  4. Antiviral prophylaxis with a nucleos(t)ide analogue such as entecavir Correct answer.

Explanation

Hepatitis B reactivation is a well-recognized complication after hematopoietic cell transplant, and antiviral prophylaxis with a potent nucleos(t)ide analogue such as entecavir reduces reactivation risk. Screening for hepatitis B surface antigen and core antibody guides prophylaxis decisions. Monitoring alone without prophylaxis is insufficient for high-risk patients.

Question 34Pre-Transplant Evaluation and Candidate Selection

Which finding on pre-transplant pulmonary function testing most strongly predicts post-transplant respiratory complications in a hematopoietic cell transplant candidate?

  1. Increased total lung capacity
  2. Elevated residual volume
  3. Mildly elevated peak expiratory flow
  4. Reduced diffusing capacity for carbon monoxide Correct answer.

Explanation

A reduced diffusing capacity for carbon monoxide reflects impaired alveolar-capillary gas exchange and is associated with increased risk of post-transplant pulmonary complications and mortality. Pulmonary function testing, including spirometry and diffusion capacity, is standard in pre-transplant evaluation. Restrictive or obstructive patterns also inform conditioning decisions.

Question 35Pre-Transplant Evaluation and Candidate Selection

Which pre-transplant laboratory assessment is most useful for estimating hepatic synthetic function in a transplant candidate?

  1. Prothrombin time and serum albumin Correct answer.
  2. Serum lactate dehydrogenase
  3. Serum creatine kinase
  4. Serum amylase and lipase

Explanation

Prothrombin time and serum albumin reflect hepatic synthetic capacity and are used alongside bilirubin and transaminases to assess liver function. Impaired synthetic function increases the risk of conditioning-related hepatotoxicity and sinusoidal obstruction syndrome. These measures help determine conditioning intensity and eligibility.

Question 36Pre-Transplant Evaluation and Candidate Selection

A patient being evaluated for transplant has a creatinine clearance of 35 mL/min. How should this most likely influence the transplant plan?

  1. The patient should receive standard full-dose myeloablative conditioning without modification
  2. Renal impairment has no bearing on transplant eligibility or drug dosing
  3. The patient requires immediate nephrectomy before conditioning
  4. Conditioning agents and supportive drugs should be dose-adjusted for renal impairment Correct answer.

Explanation

Renal impairment alters clearance of several conditioning and supportive agents, including fludarabine and melphalan metabolites, so doses must be adjusted. Reduced creatinine clearance also increases the risk of nephrotoxicity and typically prompts consideration of reduced-intensity approaches. Renal function is therefore a key pre-transplant eligibility and dosing variable.

Question 37Pre-Transplant Evaluation and Candidate Selection

In donor selection for allogeneic transplant, which human leukocyte antigen matching consideration is most important for a related donor?

  1. Matching only by ABO blood group
  2. Matching only at HLA-DRB1
  3. High-resolution matching at HLA-A, HLA-B, HLA-C, and HLA-DRB1 Correct answer.
  4. Matching by donor age alone

Explanation

High-resolution typing at HLA-A, HLA-B, HLA-C, and HLA-DRB1 is standard for identifying the best-matched related or unrelated donor. Mismatches at these loci increase the risk of graft-versus-host disease and graft failure. ABO and donor age are secondary considerations rather than primary matching criteria.

Question 38Pre-Transplant Evaluation and Candidate Selection

Which factor most commonly triggers a requirement for reduced-intensity conditioning rather than myeloablative conditioning in an older candidate?

  1. ABO incompatibility with the donor
  2. Prior history of seasonal allergies
  3. Presence of a matched sibling donor
  4. Advanced age with comorbidities limiting organ reserve Correct answer.

Explanation

Reduced-intensity conditioning is typically chosen for older patients or those with significant comorbidities that limit tolerance of myeloablative regimens. Age itself and accumulated organ dysfunction increase regimen-related toxicity. Donor type and ABO compatibility do not determine conditioning intensity.

Question 39Pre-Transplant Evaluation and Candidate Selection

A candidate for transplant has a body mass index of 42 kg/m2. Which consideration is most relevant to pre-transplant evaluation?

  1. Requirement for bariatric surgery before transplant
  2. Drug dosing based on adjusted body weight and increased risk of regimen-related toxicity Correct answer.
  3. Automatic exclusion from all transplant approaches
  4. Use of standard doses without adjustment

Explanation

Severe obesity complicates chemotherapy dosing, as lipophilic drugs may accumulate in adipose tissue, and is associated with higher rates of regimen-related toxicity and transplant complications. Dosing often uses adjusted or ideal body weight for selected agents. Obesity alone is not an absolute contraindication, and bariatric surgery is not a routine prerequisite.

Question 40Pre-Transplant Evaluation and Candidate Selection

A patient with acute myeloid leukemia in first complete remission is being evaluated for allogeneic transplant. Which factor most strongly informs the decision to proceed to transplant rather than continue chemotherapy?

  1. Cytogenetic and molecular risk stratification at diagnosis Correct answer.
  2. Donor's sex
  3. Season of diagnosis
  4. Patient's ABO blood type

Explanation

Cytogenetic and molecular risk classification identifies patients with high-risk disease who benefit most from allogeneic transplant in first remission. Risk-adapted algorithms integrate these markers with measurable residual disease and patient factors. ABO type, donor sex, and season are not determinants of transplant indication.

Question 41Pre-Transplant Evaluation and Candidate Selection

A candidate has a history of invasive aspergillosis treated six months ago with radiographic resolution. What is the most appropriate pre-transplant approach?

  1. Proceed without antifungal prophylaxis because the infection resolved
  2. Proceed with transplant while continuing mold-active antifungal prophylaxis Correct answer.
  3. Defer transplant indefinitely because prior fungal infection is an absolute contraindication
  4. Administer only antibacterial prophylaxis

Explanation

Prior invasive fungal infection is not an absolute contraindication, but patients are at high risk of recurrence during prolonged neutropenia. Mold-active antifungal prophylaxis, often with a drug such as voriconazole or posaconazole, is typically continued through the high-risk period. Radiographic resolution supports proceeding but does not eliminate the need for prophylaxis.

Question 42Pre-Transplant Evaluation and Candidate Selection

Which pre-transplant assessment best evaluates a candidate's psychosocial readiness and adherence capacity?

  1. Structured psychosocial evaluation with assessment of support systems and adherence history Correct answer.
  2. Echocardiography
  3. Bone marrow biopsy
  4. Measurement of serum albumin

Explanation

A structured psychosocial evaluation assesses social support, mental health, substance use, and prior adherence, all of which predict the ability to manage complex post-transplant care. Transplant programs commonly require this evaluation before proceeding. Laboratory and imaging tests do not address psychosocial readiness.

Question 43Pre-Transplant Evaluation and Candidate Selection

A patient with sickle cell disease is being evaluated for allogeneic transplant. Which pre-transplant consideration is most specific to this population?

  1. Assessment of iron overload and organ damage from chronic transfusion Correct answer.
  2. Assessment of ABO compatibility with the donor
  3. Measurement of thyroid-stimulating hormone
  4. Routine screening for hepatitis C only

Explanation

Patients with sickle cell disease often have chronic transfusion-related iron overload and cumulative organ damage affecting the heart, liver, and kidneys, which must be quantified before transplant. Iron chelation and organ function assessment guide conditioning choices. This burden of disease-specific organ injury distinguishes the evaluation from that of other candidates.

Question 44Pre-Transplant Evaluation and Candidate Selection

A candidate for autologous transplant has a prior history of significant cardiac amyloidosis. Why is this condition particularly concerning for transplant eligibility?

  1. It predisposes to ABO incompatibility with donors
  2. It causes restrictive cardiomyopathy and poor tolerance of fluid shifts and conditioning Correct answer.
  3. It requires lifelong anticoagulation in all cases
  4. It eliminates the need for stem cell collection

Explanation

Cardiac amyloidosis produces restrictive cardiomyopathy with impaired diastolic filling, making patients vulnerable to hemodynamic compromise during conditioning and fluid management. Careful cardiac assessment is essential before proceeding. The condition does not affect ABO compatibility or stem cell collection requirements.

Question 45Pre-Transplant Evaluation and Candidate Selection

Which pre-transplant screening test is most appropriate to identify latent tuberculosis infection in a candidate?

  1. Interferon-gamma release assay Correct answer.
  2. Serum procalcitonin
  3. Chest radiograph alone
  4. Blood cultures

Explanation

An interferon-gamma release assay detects latent tuberculosis infection and guides decisions about prophylaxis before transplant. Chest radiography alone cannot distinguish latent from active infection. Identifying and treating latent infection reduces the risk of reactivation during immunosuppression.

Question 46Pre-Transplant Evaluation and Candidate Selection

A patient with a prior autologous transplant is being considered for a second autologous transplant for relapsed myeloma. Which factor most influences eligibility?

  1. Duration of response to the first transplant and current organ function Correct answer.
  2. ABO blood type of the patient
  3. Patient's occupation
  4. Donor availability

Explanation

A durable response after the first autologous transplant, together with adequate organ function and disease control, predicts benefit from a second autologous procedure. Short remission duration and organ dysfunction argue against proceeding. Donor availability is irrelevant for autologous transplant.

Question 47Pre-Transplant Evaluation and Candidate Selection

Which pre-transplant nutritional assessment finding most warrants intervention before conditioning?

  1. Unintentional weight loss exceeding 10% of usual body weight Correct answer.
  2. Regular dietary intake
  3. Stable serum albumin
  4. Body mass index within the normal range

Explanation

Significant unintentional weight loss indicates malnutrition and depleted reserves, which increase regimen-related toxicity and post-transplant complications. Pre-transplant nutritional optimization, sometimes with enteral support, is recommended. Stable weight and normal albumin suggest adequate reserve.

Question 48Pre-Transplant Evaluation and Candidate Selection

A candidate has chronic kidney disease with a creatinine clearance of 25 mL/min and is being considered for allogeneic transplant. Which approach is most appropriate?

  1. Consider reduced-intensity conditioning with careful drug selection and renal monitoring Correct answer.
  2. Proceed with standard myeloablative busulfan and cyclophosphamide without adjustment
  3. Delay transplant until dialysis is initiated in all cases
  4. Exclude the patient because renal impairment is an absolute contraindication

Explanation

Severe renal impairment increases the risk of conditioning-related toxicity, so reduced-intensity regimens and renally appropriate drug selection are preferred. Cyclophosphamide and other agents require dose adjustment or avoidance. Renal impairment alone is not an absolute contraindication, and dialysis is not universally required.

Question 49Pre-Transplant Evaluation and Candidate Selection

Which pre-transplant evaluation is most important before selecting a haploidentical donor?

  1. Assessment of donor ABO type alone
  2. Measurement of donor serum ferritin
  3. Assessment of donor-specific anti-HLA antibodies in the recipient Correct answer.
  4. Measurement of donor blood pressure

Explanation

Donor-specific anti-HLA antibodies in the recipient can cause graft failure in haploidentical transplant, so screening is essential when selecting among related donors. Antibody profiles guide donor choice and desensitization strategies. Donor ferritin, ABO type, and blood pressure are not the primary determinants of haploidentical donor selection.

Question 50Pre-Transplant Evaluation and Candidate Selection

A patient with myelodysplastic syndrome and 20% bone marrow blasts is being evaluated for transplant. What does the blast percentage most directly influence?

  1. The need for splenectomy
  2. The selection of antiviral prophylaxis
  3. The need for pre-transplant cytoreduction and timing of transplant Correct answer.
  4. The choice of ABO-compatible donor

Explanation

A higher marrow blast percentage indicates more advanced disease and generally prompts consideration of cytoreduction before transplant to reduce relapse risk. Blast burden also influences timing and conditioning strategy. It does not determine ABO matching, splenectomy, or antiviral prophylaxis.