Transplant Surgery Practice Questions

Q: During renal transplantation, to which vessel is the renal vein connected?

External Iliac Vein. **Explanation:** In clinical renal transplantation, the donor kidney is typically placed in the **iliac fossa** (heterotopic transplantation). This location is preferred because it provides easy access to the bladder and major pelvic vessels. **1. Why External Iliac Vein is Correct:** The standard surgical technique involves performing vascular anastomoses to the iliac vessels. The **donor renal vein** is most commonly anastomosed to the **External Iliac Vein (EIV)** in an end-to-side fashion. This is because the EIV is easily accessible, has a large caliber, and lies superficially in the iliac fossa, making the venous drainage efficient. **2. Analysis of Incorrect Options:** * **Inferior Vena Cava (IVC):** While the native kidneys drain into the IVC, it is located too high (retroperitoneal) for a standard pelvic transplant. IVC anastomosis is generally reserved for pediatric recipients or specific complex cases. * **Internal Iliac Vein:** This vessel is deeper and more difficult to access than the external iliac vein. While the **Internal Iliac Artery** was historically used for the arterial anastomosis (end-to-end), the vein of choice remains the External Iliac. * **Gonadal Vein:** This vessel is far too small in caliber to accommodate the high-volume venous return from a transplanted kidney. **3. High-Yield Clinical Pearls for NEET-PG:** * **Arterial Anastomosis:** The donor renal artery is most commonly connected to the **External Iliac Artery** (end-to-side). Historically, the Internal Iliac Artery (end-to-end) was used. * **Ureteric Reimplantation:** The donor ureter is connected to the recipient's bladder using the **Lich-Gregoir technique** (extravesical ureteroneocystostomy). * **Side Selection:** Usually, the **left donor kidney** is preferred (due to a longer renal vein), but it is placed in the **right iliac fossa** of the recipient to allow the renal pelvis and ureter to lie anteriorly.

Q: Given full supportive treatment, for how long can a patient survive in the anhepatic phase?

24-48 hours. **Explanation:** The **anhepatic phase** refers to the period during liver transplantation when the native liver has been removed and the donor liver has not yet been reperfused. In a controlled surgical setting, this phase usually lasts 60–90 minutes. However, the question asks for the maximum physiological survival limit under full supportive care (e.g., in cases of total hepatectomy for trauma or "two-stage" transplantation). **1. Why 24–48 hours is correct:** The liver is the body’s primary metabolic hub. Without it, the body rapidly develops **profound hypoglycemia** (loss of gluconeogenesis), **hyperammonemia**, **lactic acidosis**, and **coagulopathy**. Even with aggressive IV glucose, bicarbonate, and clotting factor replacement, the accumulation of toxic metabolites and the loss of protein synthesis lead to irreversible cerebral edema and multi-organ failure, typically resulting in death within **24 to 48 hours**. **2. Why other options are incorrect:** * **1-2 hours:** This is the standard duration of the anhepatic phase during a routine transplant, but it is not the limit of survival with supportive care. * **1 week / 2-4 weeks:** These are far too long. No current medical technology (including "artificial livers" like MARS) can replace the liver's complex synthetic and metabolic functions well enough to sustain life for weeks without a graft. **Clinical Pearls for NEET-PG:** * **Metabolic hallmark:** The most immediate life-threatening metabolic derangement in the anhepatic phase is **hypoglycemia**. * **Hemodynamics:** During this phase, there is a significant decrease in venous return due to IVC clamping; this is often managed using a **venovenous bypass**. * **Piggyback Technique:** A surgical variation where the recipient's IVC is preserved, minimizing hemodynamic instability during the anhepatic phase.

Q: What is the most common carcinoma following renal transplantation?

Skin. **Explanation:** The most common malignancy following solid organ transplantation, including renal transplantation, is **Skin Cancer**. **1. Why Skin Cancer is the correct answer:** Post-transplant patients require lifelong **immunosuppressive therapy** (e.g., Cyclosporine, Tacrolimus, Azathioprine) to prevent graft rejection. These drugs impair the body’s immunosurveillance against oncogenic viruses and UV-induced DNA damage. * **Squamous Cell Carcinoma (SCC)** is the most frequent subtype (unlike the general population where Basal Cell Carcinoma is more common). * The risk of SCC in transplant recipients is increased up to 65–100 times compared to the general population. **2. Analysis of Incorrect Options:** * **B. Renal Cell Carcinoma (RCC):** While there is an increased risk of RCC in the native kidneys (especially in patients with Acquired Cystic Kidney Disease), it is significantly less common than skin malignancies. * **C. Lung Cancer:** Although the risk of various solid tumors increases post-transplant due to immunosuppression, lung cancer does not reach the high incidence rates seen in skin cancers. * **D. Adrenal Carcinoma:** This is a rare malignancy and is not specifically associated with the post-renal transplant period. **3. High-Yield Facts for NEET-PG:** * **Most common malignancy overall:** Skin Cancer (SCC > BCC). * **Most common non-skin malignancy:** Post-Transplant Lymphoproliferative Disorder (PTLD), often associated with **EBV infection**. * **Kaposi Sarcoma:** Highly associated with **HHV-8** in transplant patients. * **Screening:** Transplant recipients require aggressive annual dermatological screening and strict sun protection.

Q: What is the indication for liver transplantation that is associated with the best prognosis?

Chronic liver failure. **Explanation:** Liver transplantation is the definitive treatment for end-stage liver disease. The prognosis following transplantation is primarily determined by the underlying etiology and the pre-operative physiological state of the patient. **Why Chronic Liver Failure is the Correct Answer:** Patients with **Chronic Liver Failure** (specifically those with compensated or stable cirrhosis, such as Primary Biliary Cholangitis) generally have the best long-term survival rates. This is because these patients are often chronologically stable, allowing for optimized pre-operative preparation. Among all indications, **Primary Biliary Cholangitis (PBC)** is historically associated with the highest post-transplant survival rates (often exceeding 90% at 5 years). **Analysis of Incorrect Options:** * **A. Acute Liver Failure (ALF):** While life-saving, ALF carries a higher perioperative mortality risk due to complications like cerebral edema, multi-organ failure, and severe systemic inflammation. * **C. Malignancy:** Patients transplanted for Hepatocellular Carcinoma (HCC) face the risk of tumor recurrence, especially if they fall outside the Milan Criteria. This significantly lowers long-term survival compared to non-malignant chronic failure. * **D. Metabolic Liver Disease:** While outcomes are generally good, certain metabolic conditions (like Wilson’s disease presenting as ALF) carry higher acute risks, and others may involve extra-hepatic manifestations that complicate recovery. **High-Yield Clinical Pearls for NEET-PG:** * **Most common indication (Worldwide):** Hepatitis C related cirrhosis (historically) and NASH/NAFLD (rising). * **Most common indication (Children):** Biliary Atresia. * **Milan Criteria for HCC:** Single lesion <5cm or up to 3 lesions each <3cm. * **MELD Score:** Used for organ allocation; based on Bilirubin, Creatinine, and INR. * **Best Prognostic Etiology:** Primary Biliary Cholangitis (PBC).

Q: Transplantation of which one of the following organs is most often associated with hyperacute rejection?

Kidney. **Explanation:** **Hyperacute rejection** is a type II hypersensitivity reaction mediated by pre-formed antibodies (anti-HLA or anti-ABO) in the recipient’s serum. These antibodies bind to the donor vascular endothelium immediately upon reperfusion, leading to complement activation, thrombosis, and graft necrosis. **Why Kidney is the correct answer:** The **Kidney** is the organ most frequently associated with hyperacute rejection. This is primarily because kidneys are highly vascularized and the renal endothelium is particularly sensitive to antibody-mediated damage. Historically, the kidney was the first organ where this phenomenon was extensively studied, leading to the mandatory requirement of the **Pre-transplant Cross-match** (mixing recipient serum with donor lymphocytes) to prevent this occurrence. **Analysis of Incorrect Options:** * **Heart (A) and Lungs (C):** While hyperacute rejection can occur in these organs, it is clinically rarer than in kidneys because cross-matching is strictly performed, and the sheer volume of kidney transplants performed globally makes it the most common clinical association. * **Liver (D):** The liver is considered **"immunologically privileged"** in the context of hyperacute rejection. It has a dual blood supply, a large endothelial surface area that can "sponge up" or dilute antibodies, and the ability to clear immune complexes, making hyperacute rejection extremely rare in liver transplants. **High-Yield Clinical Pearls for NEET-PG:** * **Timeline:** Occurs within **minutes to hours** of transplantation (often seen "on the table"). * **Gross Appearance:** The organ becomes mottled, cyanotic, and flaccid. * **Pathology:** Fibrinoid necrosis of capillaries and widespread microvascular thrombosis. * **Management:** There is no treatment; the graft must be **immediately removed**. * **Prevention:** Perform a **CDC (Complement Dependent Cytotoxicity) cross-match**.

Question 1

What is the first sign or symptom of renal graft rejection?

Accepted Answer

Increased creatinine on examination

Answer

Fever

Answer

Rash

Answer

Tenderness

Question 2

A 32-year-old man is stable one year post-kidney transplant. Which of the following complications of transplantation is the most likely cause of death?

Accepted Answer

Atherosclerosis

Answer

Opportunistic infection

Answer

Lymphoma

Answer

Persistent hyperparathyroidism

Question 3

During renal transplantation, to which vessel is the renal vein connected?

Accepted Answer

External Iliac Vein

Answer

Inferior Vena Cava (IVC)

Answer

Internal Iliac Vein

Answer

Gonadal Vein

Question 4

Given full supportive treatment, for how long can a patient survive in the anhepatic phase?

Accepted Answer

24-48 hours

Answer

1-2 hours

Answer

1 week

Answer

2-4 weeks

Question 5

What is the most common carcinoma following renal transplantation?

Accepted Answer

Skin

Answer

Renal cell carcinoma

Answer

Lung

Answer

Adrenal carcinoma

Question 6

Which of the following are absolute contraindications for heart transplantation?

Accepted Answer

HIV infection, irreversible pulmonary hypertension, malignancy

Answer

HIV infection, irreversible pulmonary hypertension, significant pulmonary vascular disease

Answer

Age > 60 years, significant pulmonary vascular disease, malignancy

Answer

HIV infection, age > 60 years, significant pulmonary vascular disease

Question 7

What is the indication for liver transplantation that is associated with the best prognosis?

Accepted Answer

Chronic liver failure

Answer

Acute liver failure

Answer

Malignancy

Answer

Metabolic liver disease

Question 8

Which of the following statements is true regarding successful whole-organ pancreas transplantation in type I diabetes?

Accepted Answer

The pathologic changes of diabetic retinopathy are reversed.

Answer

It results in the maintenance of normal serum glucose levels.

Answer

Recurrence of diabetic nephropathy in simultaneously transplanted kidneys is not prevented.

Answer

Oral glucose tolerance tests remain abnormal.

Question 9

Transplantation of which one of the following organs is most often associated with hyperacute rejection?

Accepted Answer

Kidney

Answer

Heart

Answer

Lungs

Answer

Liver

Question 10

All of the following are true about liver transplantation except?

Accepted Answer

Alcoholic liver disease is the most common indication for liver transplantation.

Answer

Two recipients benefit from split liver transplantation.

Answer

Choledocho-choledochostomy is preferred over choledochojejunostomy.

Answer

The sequence of anastomosis is: 1. Suprahepatic IVC, 2. Infrahepatic IVC, 3. Portal vein, 4. Hepatic artery, 5. Bile duct.

Transplant Surgery — MCQs

Transplant Surgery — MCQs

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