Scenario 1 - 1 File Download



1Theme: Complications following kidney transplantationA Acute graft rejectionB Chronic graft rejectionC Delayed graft functionD LymphoceleE Renal artery stenosisF Ureteric obstructionFor each of the clinical scenarios listed below, select the most likely complication. Each option may be used once, more than once, or not at all.Scenario 16 months following transplantation a patient is seen in clinic with a mild swelling and tenderness in the region of the transplant. Their renal function has deteriorated. A computed tomography (CT) scan demonstrates a collection between the lower pole of the kidney and bladder.D - Lymphocele?? CORRECT ANSWERLeakage from perivascular lymphatic vessels can lead to significant collections of lymph between the lower pole of the transplanted kidney and the bladder. A lymphocele can present as pain, swelling and impaired renal function within the first year following transplantation. Treatment is by drainage. Percutaneous drainage has a high infection risk and is rarely successful, due to a high recurrence rate. Laparoscopic drainage of the collection in to the abdominal cavity is the treatment of choice.YOUR ANSWER WAS CORRECTScenario 2You are referred a patient by their general practitioner (GP). They underwent a renal transplantation 3 years ago. The patient has been complaining of headaches and dizzy spells. The GP reports an abrupt onset of unexplained hypertension.E - Renal artery stenosis?? CORRECT ANSWERRenal artery stenosis complicates 2–10% of renal transplants. It may be confirmed on Doppler ultrasound. It can be managed using percutaneous angioplasty and stent placement.YOUR ANSWER WAS CORRECTScenario 3You review a 50-year-old man in clinic. He had a renal transplantation 200 days ago. He feels tired but otherwise well. His renal function is deteriorating and he has developed proteinuria.B - Chronic graft rejection?? CORRECT ANSWERThis gentleman has chronic allograft nephropathy. It is characterised by slowly progressive graft dysfunction which leads to chronic renal failure. In addition many patients develop nephrotic-range proteinuria. Histopathological examination of a renal allograft biopsy may show varying combinations of lesions. These include: chronic transplant glomerulopathy, ischaemic glomerulopathy, interstitial fibrosis, tubular atrophy, arteriosclerosis and arteriolar hyalinosis.2Theme: Transplant rejectionA Accelerated rejectionB Acute rejectionC Chronic rejectionD Hyperacute rejectionE Not undergoing rejectionF Severe acute rejectionFor each of the clinical scenarios listed below, select the most likely answer. Each option may be used once, more than once, or not at all.Scenario 1You are assisting with a renal allograft transplantation. Once perfusion of the kidney is established it becomes grossly mottled and cyanotic. The capsule begins to bulge.D - Hyperacute rejection?? CORRECT ANSWERThe kidney is undergoing antibody mediated hyperacute rejection. This generally occurs within 24 h of the operation. In severe cases it can occur following perfusion of the allograft. It is an irreversible process and the patient will have to restart dialysis.YOUR ANSWER WAS CORRECTScenario 2You review a 45-year-old woman on the ward round. She had a renal transplantation 5 days ago. She is complaining of some discomfort in the region of the transplant. Her renal function had been improving but has now deteriorated over the last two days.A - Accelerated rejection?? CORRECT ANSWERAccelerated rejection develops up to a week after transplantation. It is generally due to cell-mediated immune injury. Both delayed hypersensitivity and cytotoxicity mechanisms are likely to be involved. It is usually irreversible.Scenario 3You receive the histopathology report for a patient who you suspect is rejecting the kidney transplant received 90 days ago. The findings are of, ‘transmural arteritis and transmural fibrinoid change with necrosis of smooth muscle cells’.F - Severe acute rejection?? CORRECT ANSWERAcute rejection occurs between a week and 100 days following transplantation. The severity of rejection can be assessed by taking a needle biopsy of the allograft. Acute rejection is recognised by the presence of tubulitis and intimal arteritis. The?Banff?System can be used to classify acute rejection into mild, moderate, and severe. The category depends on the intensity of the infiltrate, and the severity of tubulitis and intimal arteritis. In this case there was also necrosis of muscle cells which means it is grade 3 and therefore severe acute rejection.Scenario 4You review a 50-year-old man in clinic. He had a renal transplantation 200 days ago. He feels tired but otherwise well. His renal function is deteriorating and he has developed proteinuria.C - Chronic rejection?? CORRECT ANSWERThis gentleman has chronic allograft nephropathy. It is characterised by slowly progressive graft dysfunction which leads to chronic renal failure. In addition, many patients develop nephrotic-range proteinuria.Histopathological examination of a renal allograft biopsy may show varying combinations of lesions. These include: chronic transplant glomerulopathy, ischaemic glomerulopathy, interstitial fibrosis, tubular atrophy, arteriosclerosis and arteriolar hyalinosis.YOUR ANSWER WAS CORRECT3A 64-year-old male who underwent a liver transplant 6 years earlier presents to his GP with a lesion on his lower lip that bleeds intermittently. On examination it is a small ulcerated lesion with raised edges. He reports it has been present for 4 months and is not healing.What is the most likely nature of this lesion?Select one answer onlyCandida albicansKaposi sarcoma?? YOUR ANSWERMelanomaSquamous cell carcinoma?? CORRECT ANSWERGingival hypertrophyYOUR ANSWER WAS INCORRECTThe AnswerComment on this QuestionLong term immunosuppression for successful organ transplantation carries a number of important side effects such as malignant disease in particular squamous cell carcinoma. This has a number of different appearances, but is can be a non-healing ulcer often with slightly everted edges. Transplant patients are often followed up long term to screen for the development of skin cancers secondary to immunosuppression.4A 35-year-old male receives a renal transplant from an unrelated donor for dialysis-dependent renal disease. The transplanted organ is placed in the right iliac fossa.What type of transplant is this?Select one answer onlyAutograftIsograftHeterotopic graft?? YOUR ANSWEROrthotopic graftXenograftYOUR ANSWER WAS CORRECTThe AnswerImportant terms to understand in transplant surgery are as follows:Autograft - transplant of tissue from one location to another in the same individualIsograft - transplant of tissue between genetically identical individuals e.g. identical twinsAllograft - transplantation of an organ or tissue between genetically different individuals from the same speciesXenograft - transplantation of organs between different speciesOrthotopic graft - transplantation of a donor organ to the same anatomical site in a recipientHeterotopic graft - transplantation of a donor organ to a different anatomical site than that of the existing kidneys in a recipient5Theme: Patient selection for transplantationA Candidate in future following lifestyle changeB Further medical management before considerationC Further surgical management before considerationD High-priority candidateE Low-priority candidateF Standard priority candidateG Unsuitable candidateFor each of the clinical scenarios listed below, select the most likely patient classification. Each option may be used once, more than once, or not at all.Scenario 1You see a fit 50-year-old woman being assessed for renal transplantation. An ultrasound scan of her abdomen has revealed multiple gallstones. She has had the occasional bout of right upper quadrant pain but thought nothing of it. Liver function tests are normal.C - Further surgical management before consideration?? CORRECT ANSWERGallstones are a relative contraindication for renal transplantation. She requires a cholecystectomy before being put forward for a renal transplant.YOUR ANSWER WAS CORRECTScenario 2You see an 18-year-old girl on the high-dependency unit. She was admitted 3 days ago following a paracetamol overdose. She has severely deranged liver function tests and is developing renal impairment. Her Glasgow Coma Score (GCS) is 13/15. She was previously fit and well.D - High-priority candidate?? CORRECT ANSWERParacetamol overdose can cause death by acute liver failure. The cause of early deaths is usually raised intracranial pressure. Later deaths can occur from multiorgan failure and systemic sepsis. If a patient survives the acute phase without a transplant, the liver will tend to recover without the development of cirrhosis.Scenario 3A 40-year-old type I diabetic with end-stage renal failure is seen in the renal transplant clinic. His body mass index (BMI) is 31 and he smokes 20 cigarettes a day.A - Candidate in future following lifestyle change?? CORRECT ANSWERSmoking and obesity are contraindications to renal transplantation.Scenario 4You see a 38-year-old woman in clinic following a full assessment for a liver transplant. She has end-stage liver disease secondary to primary biliary cirrhosis. She has been feeling very tired. On examination she looks jaundiced and has ascities for which she is taking diuretics. Blood tests reveal creatinine 220 mmol/l and international normalised ratio (INR) 2.4.D - High-priority candidate?? CORRECT ANSWERThe three top causes of end-stage liver disease leading to liver transplantation in the?UK?are alcohol, hepatitis C and primary biliary sclerosis. It is often difficult to prioritise patients. In the?USA they use the?Model for End-Stage Liver Disease (MELD) scoring system. The MELD score is based on three biochemical variables, 1/serum bilirubin, 2/serum creatinine and 3/international normalised ratio (INR). Retrospective and prospective studies have shown it to be highly predictive of 3-month mortality in patients with chronic liver disease. The higher the MELD score, the higher priority the patient.6Theme: Types of tissue transplantationA AutograftB AllograftC MonograftD IsograftE XenograftFor each of the clinical scenarios listed below, select the most appropriate description of the transplanted tissue. Each option may be used once, more than once, or not at all.Scenario 1A patient receives a porcine aortic valve replacement.E - Xenograft?? CORRECT ANSWERA xenograft (or heterograft) is an organ or tissue transferred from one species to another species.YOUR ANSWER WAS CORRECTScenario 2A 25-year-old woman with end-stage renal failure receives a kidney for transplantation from her identical twin sister.D - Isograft?? CORRECT ANSWERAn isograft is an organ or tissue obtained from a donor genetically identical to the recipient.YOUR ANSWER WAS CORRECTScenario 3A woman undergoes renal transplantation. The kidney had been harvested from a patient with confirmed brainstem death.B - Allograft?? CORRECT ANSWERAn allograft (or homograft) is an organ or tissue transplanted from a donor of the same species but different genetic make-up.YOUR ANSWER WAS CORRECTScenario 4A 16 year-old boy suffers burns to h is chest. A part ial-th ickness sk in graft is harvested from h is th igh and used to cover part of h is chest.A - Autograft?? CORRECT ANSWERAn autograft is tissue taken from one site and grafted to another site on the same person.YOUR ANSWER WAS CORRECT7Theme: Renal transplantA Acute rejectionB Blood group mismatchC Chronic rejectionD Hyperacute rejectionMatch the following concerning transplantation. Each option may be used only once.Scenario 1This type of rejection may take years to occurC - Chronic rejection?? CORRECT ANSWERC – Chronic rejectionMany factors involved - may be the humoral immune system or cell-mediated, and may take months or years to occur.YOUR ANSWER WAS CORRECTScenario 2Cellular immunity is responsible for this.A - Acute rejection?? CORRECT ANSWERA – Acute rejectionAcute rejection occurs as a result of HLA type mismatch, and is controlled by matching donor and recipient HLA types and with immunosuppressive drugs.YOUR ANSWER WAS CORRECTScenario 3This causes haemolysis.B - Blood group mismatch?? CORRECT ANSWERB – Blood group mismatchYOUR ANSWER WAS CORRECTScenario 4Pre-sensitisation is responsible for this.D - Hyperacute rejection?? CORRECT ANSWERD – Hyperacute rejectionHyperacute rejection occurs immediately, as a result of a rejection from pre-existing bodies to the transplanted tissue, eg ABO blood type mismatch.YOUR ANSWER WAS CORRECT8A 57-year-old male received a renal transplant from an unrelated donor 15 years earlier and has had no rejection problems post-operative. He is noted by his dentist during a routine check-up to have gingival hypertrophy.Which of his medications is likely to be causing this?Select one answer onlyAzathioprine?? YOUR ANSWERCyclosporin?? CORRECT ANSWERMycophenolatemofetilPrednisoloneRituximabYOUR ANSWER WAS INCORRECTThe AnswerAll immunosuppressive medications carry important side effects, it is important to be aware of these. Azathioprine can cause myelosuppression and acute pancreatitis. Steroids such as prednisolone carry numerous side effects such as Cushing’s syndrome. Cyclosporin can cause gingival hypertrophy in addition to nephrotoxicity, hepatotoxicity and neurotoxicity. Mycophenolate mofetil can also cause bone marrow suppression and patients require regular full blood counts upon starting it. Rituximab is a monoclonal anitibody that can also be used for lymphomas. Its can cause cardiac problems such as exacerbation of angina, heart failure and arrhythmias.9Theme: Drug therapy for suspected transplant rejectionA Antithymocyte globulin (ATG)B AzothioprineC CiclosporinD MethotrexateE MycophenolateF MethylprednisoloneFor each of the clinical scenarios listed below, select the most appropriate first-line drug therapy. Each option may be used once, more than once, or not at all.Scenario 1You receive a histopathology report for a patient who you suspect is rejecting the renal allograft they received 90 days ago. The findings are of ‘transmural arteritis and transmural fibrinoid change with necrosis of smooth muscle cells’.F - Methylprednisolone?? CORRECT ANSWERFirst-line therapy in acute rejection is high-dose steroids in addition to the original immunoprophylaxis.Scenario 2You review a 45-year-old woman on the ward round. She had a renal transplantation one week ago. She is now complaining of discomfort in the region of the transplant. Her renal function had been improving but has deteriorated over the last two days.F - Methylprednisolone?? CORRECT ANSWERFirst-line therapy in acute rejection is high-dose steroids in addition to the original immunoprophylaxis.Scenario 3A patient with established acute graft versus host rejection is 30 days following renal transplantation. They have been receiving first line therapy for 7 days but there has been no change in their conditionA - Antithymocyte globulin (ATG)?? CORRECT ANSWERFailure of first-line therapy is defined as progression of acute graft versus host disease after 3 days, no change after 7 days, or incomplete response after 14 days of methylprednisolone. Secondary therapy includes?ATG and monoclonal antibody therapy.10Theme: Consent for organ donationA Discuss organ donation with relativesB Seek consent from the coronerC Respect relatives wishes, unable to go ahead with organ harvestD Invalid consent, unable to go ahead with organ harvestE Not suitable for organ donationF Valid consent, proceed with organ harvestFor each of the clinical scenarios listed below, select the most likely course of action. Each option may be used once, more than once, or not at all.Scenario 1A 25-year-old man is on the intensive therapy unit (ITU) following a severe head injury. He has been confirmed brainstem dead. He is a suitable candidate for organ donation but is not on the organ donation register (ODR). His relatives say he never expressed a wish to donate his organs. They themselves do not object and agree with donation.B - Seek consent from the coroner?? CORRECT ANSWERB - Seek consent from the coronerThe coroner would have to be contacted and if he consents then one can proceed with organ procurement.Scenario 2Brainstem death is confirmed in a 34-year-old woman on ITU. She is on the organ donation register. You discuss this with her relatives and they object to organ donation.F - Valid consent, proceed with organ harvest?? CORRECT ANSWERF - Valid consent, proceed with organ harvestThe patient had expressed a wish to donate her organs by registering with the organ donation register (ODR). There is no evidence that the patient changed her mind before death. Her relatives holding an opposing view does not invalidate the consent. Time should be spent with the relatives fully informing them about organ donation and address any issues they have.NB: It is very important that candidates realise that in reality, transplant teams are unlikely to proceed with organ harvesting unless the donor’s relatives are also agreeable to this. This scenario may arise in the MRCS Part B exam (e.g. as a communication station) and every effort must be made to provide information and seek agreement from the relatives, failing which, senior advice must be sought.YOUR ANSWER WAS CORRECTScenario 3A 46-year-old man is on ITU following a road traffic collision. He has been confirmed brainstem dead. He is a suitable candidate for organ donation but is not on the register. He does not have any close relatives. A friend is not sure what his wishes would have been.B - Seek consent from the coroner?? CORRECT ANSWERB - Seek consent from the coronerThe Human Tissue Act (1961) states that only the person lawfully in possession of the body or his/her designated other can authorise the removal of organs or tissues from the body. It states:“The person lawfully in possession of the body has powers and duties in connection with removal of organs. The person authorises the removal of any part from the body for the said purposes (therapeutic or medical education, or research) if having made such reasonable enquiry as may be practicable, he has no reason to believe: (a) that the deceased had expressed an objection to his body being so dealt with after his death, and had not withdrawn it; or (b) that the surviving spouse or any surviving relative of the deceased objects to the body being so dealt with.”Where a deceased person is in an NHS hospital or organisation, the person with control and management of the hospital (usually the chief executive/medical director) is the person lawfully in possession of the body until such time as it is claimed by the person who has right to possession for the purpose of disposal (usually the executor or next of kin of the patient) or, by reason of their statutory obligations, the coroner or procurator fiscal (Department of Health Working Party – Code of Practice for the Diagnosis of Brain Stem Death 1998).In situations where the cause of death was sudden, not due to natural causes or unexpected and/or the doctor has not treated the deceased during his/her last illness, the coroner/procurator fiscal must be informed (Coroner’s Act 1988). The medical staff involved in the care of the patient should contact the coroner/procurator fiscal to obtain authorisation for organ/tissue donation or the donor transplant co-ordinator/tissue co-ordinator may do this on behalf of the medical staff.YOUR ANSWER WAS CORRECTScenario 4A 50-year-old woman on ITU is confirmed brainstem dead. She is on the ODR and her relatives have already expressed a wish that her organs are harvested. According to her relatives she is fit and well. In the past she has been ‘cured’ following treatment for early breast cancer, for which she was given the 'all clear' 7 years ago.F - Valid consent, proceed with organ harvest?? CORRECT ANSWERF - Valid consent, proceed with organ harvestThe Advisory Committee on the Safety of Blood, Tissues and Organs issued revised guidelines in April 2014. Organ donation is not permitted from patients with a history of metastatic cancer or any form of haematological malignancy (e.g. leukaemia or lymphoma) or cerebral lymphoma. Although certain tumours are considered ‘high risk’ (e.g. melanoma, breast cancer, lung cancer, bowel cancer, renal cancer and sarcoma), individuals with these tumours may still be organ donors if their cancer was at an early stage, and treated successfully without evidence of recurrence for over 5 years. Please see UK Transplant website () for further information.11Theme: Conditions leading to kidney transplantationA Chronic glomerulonephritisB Diabetes mellitusC Hypertensive nephrosclerosisD Chronic interstitial nephritisE Polycystic kidney diseaseF Systemic lupus erthematoususFor each of the clinical scenarios listed below, select the most likely diagnosis. Each option may be used once, more than once, or not at all.Scenario 1A 51-year-old Asian woman is seen in clinic. She is complaining of feeling tired and passing foamy urine. On examination she has ankle swelling. Her urine is positive for glucose and protein.B - Diabetes mellitus?? CORRECT ANSWERDiabetic nephropathy is the leading cause of chronic renal failure in Western societies. It is also one of the most significant long-term complications in terms of morbidity and mortality for individual patients with diabetes. Diabetes is responsible for 30–40% of all end-stage renal disease.Scenario 2A 50-year-old woman is seen in the renal clinic. She has been referred because of a raised creatinine and mild proteinuria. She has been taking long-term non-steroidal anti-inflammatory drugs for low back pain.D - Chronic interstitial nephritis?? CORRECT ANSWERAnalgesic nephropathy is the most common cause of chronic interstitial nephritis worldwide. It has an insidious nature and is often diagnosed incidentally on routine blood tests or evaluation of hypertension. Patients are usually asymptomatic. Clinical investigations may show modest elevation in serum creatinine and evidence of renal tubular acidosis. Proteinuria is usually mild (<1 g/dl).YOUR ANSWER WAS CORRECTScenario 3You see a 48-year-old man on the ward who is awaiting a renal transplantation. He is receiving haemodialysis. He is anaemic and is being treated for hypertension. He has proteinuria of >1g/day. His renal biopsy showed his renal tubules were disrupted and atrophic with marked interstitial fibrosis and arterial and arteriolar sclerosis.A - Chronic glomerulonephritis?? CORRECT ANSWERChronic glomerulonephritis is characterised by irreversible and progressive glomerular and tubulointerstitial fibrosis, ultimately leading to a reduction in the glomerular filtration rate (GFR) and retention of toxins.Scenario 4You see a 55-year-old man with end-stage renal failure. He says his father also had problems with his kidneys. On examination he has bilateral balottable masses in his flanks.E - Polycystic kidney disease?? CORRECT ANSWERAutosomal dominant polycystic kidney disease (ADPKD) is one of the most common inherited disorders in humans. It is the most frequent genetic cause of renal failure in adults.YOUR ANSWER WAS CORRECT12Theme: Complications of cadaveric organ transplantationA Acute rejectionB Arterial thrombosisC Azathioprine side-effectsD Chronic rejectionE Cyclosporin side-effectsF Cytomegalovirus infectionG Graft-versus-host diseaseH Hyperacute rejectionI MalignancyJ Primary graft non-functionK Steroid side-effectsL Venous thrombosisThe following patients have all previously undergone cadaveric organ transplantation. From the above list, select the most likely complication. The items may be used once, more than once, or not at all.Scenario 1A 25-year-old woman with cystic fibrosis underwent a heart and lung transplant 4 months ago, and is currently receiving triple immunotherapy. She attends the follow-up clinic for a routine check-up. She reports sore gums and excessive facial hair. On examination she is hypertensive. Urea & electrolyte results are as follows: Na+?139 mmol/litre, K+?5.7 mmol/litre, urea 9.9 mmol/litre, creatinine 140 ?mol/litre.E - Cyclosporin side-effects?? CORRECT ANSWERE – Cyclosporin side-effectsCyclosporin A is an example of a calcineurin inhibitor. Cyclosporin-based triple immunosuppression with corticosteroids and azathioprine remains the most popular regimen in theUK. It is used prophylactically and therapeutically to address rejection following organ transplantation. Side effects of cyclosporin include nephrotoxicity, hypertension, hirsutism, tremor, gingival hyperplasia and hepatotoxicity. Long-term use increases the risk of development of malignancy (5% of patients), most commonly basal or squamous cell carcinomas.YOUR ANSWER WAS CORRECTScenario 2A 58-year-old man had a liver transplant 7 weeks ago. He attends The Emergency Department with a 24-h history of malaise, fever and myalgia and respiratory distress going upstairs. He is currently receiving triple immunosuppression. On examination, he is unwell and dyspnoeic at rest. He has a pulse rate of 105/min, blood pressure is 95/60 mmHg, temperature is 38.3°C and respiratory rate is 28 breaths/min. Oxygen saturation is 90% on air.F - Cytomegalovirus infection?? CORRECT ANSWERF – Cytomegalovirus infectionIn addition to the development of malignancy, immunosuppression increases the risk of infection. Cytomegalovirus (CMV) is a member of the herpes group of viruses. Primary infection in a seronegative individual who receives a graft from a seropositive donor typically occurs 6 weeks post transplantation, and results in the most severe disease. The main symptoms of CMV infection are usually non-specific and include fever, night sweats, fatigue and myalgia. Retinitis is pathognomonic, but rarely seen in the transplant population. Respiratory distress, noticed at first during exercise, may give a clue to early CMV pneumonitis. Patients may also present with CMV encephalitis or gastrointestinal infection, characterised by dysphagia, diarrhoea, nausea and abdominal pain. Reactivation of latent CMV infection may also occur in immunosuppressed patients, although the infection is usually less severe.YOUR ANSWER WAS CORRECTScenario 3A 41-year-old woman underwent renal transplantation 18 months ago. She attends follow-up clinic and is currently asymptomatic. On examination her blood pressure is 150/110 and urinalysis reveals 3+?protein. Urine culture is negative. A renal ultrasound scan reveals a normal collecting system. Renal biopsy demonstrates intrarenal arteriosclerosis with associated glomerular atrophy and interstitial fibrosis.D - Chronic rejection?? CORRECT ANSWERD – Chronic rejectionChronic rejection is characterised clinically by a progressive deterioration in graft function occurring months to years after transplantation and is associated with typical histological changes of graft atherosclerosis and fibrosis. By contrast, acute rejection occurs within the first 3 months after transplantation, and hyperacute rejection occurs within hours. For the diagnosis of chronic rejection to be made, other causes of graft dysfunction must be excluded (eg infection, calcineurin antagonist toxicity, etc), and a transplant graft biopsy is required to confirm the diagnosis histologically. For renal transplantation, graft dysfunction is manifested by a rise in serum creatinine as a result of progressive decline in the glomerular filtration rate. There is associated proteinuria and worsening hypertension, with the diastolic component classically rising in advance of the systolic componentYOUR ANSWER WAS CORRECT13Theme: Complications following liver transplantationA Primary graft failureB Biliary obstructionC Chronic graft rejectionD Hepatic artery thrombosisE HepatitisF Normal postoperative courseG Post-transplant lymphoproliferative disorderFor each of the clinical scenarios listed below, select the most likely diagnosis. Each option may be used once, more than once, or not at all.Scenario 1At the 6-month review following a liver transplant a patient says they feel unwell. He/she has been feeling tired, have a sore throat and night sweats. According to your notes he/she has also lost weight.G - Post-transplant lymphoproliferative disorder?? CORRECT ANSWERPost-transplant lymphoproliferative disorders (PTLDs) may develop at any time after transplantation. They are usually associated with Epstein–Barr virus infection and are a consequence of the high level of immunosuppression achieved with current regimens. The usual management is to reduce the immunosuppression and treatment with acyclovir.Scenario 25 days post-transplant a patient develops a high temperature and their liver function tests have deteriorated. Blood cultures are positive for?Escherichia coli.D - Hepatic artery thrombosis?? CORRECT ANSWERA 1/high temperature, 2/deranged liver function tests and 3/positive blood cultures in the postoperative period following liver transplantation is virtually pathognomic of hepatic artery thrombosis. Doppler ultrasound is used to assess hepatic artery patency. Arteriography can be used if Doppler fails to visualise the artery. Patients presenting in the early postoperative period usually require re-transplantation.Scenario 32 days post-transplant a patient deteriorates and has a seizure. Blood tests show grossly deranged liver function tests and confirm a suspected coagulopathy.A - Primary graft failure?? CORRECT ANSWERApproximately 7% of grafts undergo primary failure. It is a very serious complication with a poor prognosis. Urgent re-transplantation is required.YOUR ANSWER WAS CORRECT14A 45-year-old female is undergoing a liver transplant for advanced primary biliary cirrhosis after a failure to respond to medical therapy. It is decided to perform a piggy-back transplant.What will the donor inferior vena cava be anastomosed to in this case?Select one answer onlyAzygos veinHepatic vein?? CORRECT ANSWERInferior vena cava?? YOUR ANSWERRenal veinSplenic veinYOUR ANSWER WAS INCORRECTThe AnswerIn a conventional liver transplant the donor inferior vena cava (IVC) is anastomosed to the recipient IVC and this entails an inevitable anhepatic phase of transplantation. This carries a number of potential problems such as reducing venous return to the heart and possibly causing portal venous congestion. To reduce these potential problems, venovenous bypass has been used. This however can also contribute to problems relating to the use of an extra-corporeal circuit e.g. hypothermia and vascular access problems e.g. lymphocoele formation. The use of piggy back transplantation has therefore been developed, this involves anastomosing the donor’s suprahepatic vena cava to the recipient hepatic veins.?15A 54-year-old female with chronic glomerulonephritis requires a renal transplant as she has end-stage renal failure.The renal artery and vein of the donor are most likely to be anastomosed to which vessels of the recipient in end to side anastomosis?Select one answer onlyAorta and inferior vena cavaExternal iliac artery and vein?? YOUR ANSWERFemoral artery and veinInternal iliac artery and veinRenal artery and veinYOUR ANSWER WAS CORRECTThe AnswerThe kidney is placed extraperitoneally in the right or left iliac fossa, usually on the right side (dictated by existing scars or previous transplants and because it is relatively straightforward to access for biopsies and surgery in the event of post-operative problems). Renal vessels are anastomosed (end to side) to the recipient’s external iliac verssels. The ureter is taken down into the pelvis where it is anastomosed to the bladder mucosa, either directly (extravesical approach) or by threading it through a submucosal tunnel and suturing from inside the bladder through a separate incision in the bladder wall (intravesical approach).End-to-end anastomosis is to the internal iliac artery. ................
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