Snapshot A 60-year-old-man presents with nausea and vomiting to his primary care physician. Medical history is significant for a liver transplantation approximately 2 weeks prior to presentation. On physical examination there is scleral icterus and mild ascites. A liver biopsy shows lymphocytic infiltrates in the interstitium. (Acute rejection) Introduction Transplantation is a process by which cells, tissues, or organs (a graft) from the donor are transplanted into a host (or recipient) The immune system's ability to recognize and respond to foreign antigens bring challenges to transplantation There are several types of grafts autograft tissue is moved from one location to another in the same person e.g., skin graft and using the saphenous vein to replace a coronary artery the graft will not be considered foreign and thus will not require lifelong immunosuppresion syngeneic graft (isograft) tissue is transplanted from one genetically identical donor to the host e.g., transplantation between monozygotic twins allograft tissue is transplanted from one genetically different donor of the same species to the host e.g., kidney transplant xenograft tissue is transplanted from a donor of a different species to the host e.g., porcine heart valve Transplant Rejection Transplant Rejection Rejection Type Pathogenesis Comments Hyperacute Type II hypersensitivity reaction where pre-existing recipient antibodies attack the donor antigen resulting in complement activation endothelial damage inflammation thrombosis Time minutes to hours Findings capillary thrombosis which prevents graft vascularization Acute Cellular rejection type IV hypersensitivity reaction where recipient CD8+ T-cells react to donor antigens after activation by antigen presenting cells Humoral rejection just like in hyperacute rejection; however, the antibodies are formed after transplantation occured Time weeks to months Findings graft vessel vasculitis with lymphocytic infiltrates Chronic Type II and IV hypersensitivity reaction secondary to CD4+ T-cells responding to the host's antigen presenting cells Time months to years Findings cytokine secretion after T-cell activation leads to smooth muscle proliferation interstitial fibrosis parenchymal atrophy Graft-versus-host disease Type IV hypersensitivity reaction secondary to the donor's T-cells attacking the recipient's cells leading to organ dysfunction Time variable Findings maculopapular rash jaundice diarrhea hepatosplenomegaly Tissue Compatibility Testing ABO blood typing Tissue typing used to see if HLA antigens match and focuses on HLA-A HLA-B HLA-DR References
QUESTIONS 1 of 10 1 2 3 4 5 6 7 8 9 10 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.IM.15.74) A 45-year-old female is undergoing renal transplantation for management of chronic renal failure secondary to glomerulonephritis. The transplant surgeon placed the donor kidney in the recipient and anastamosed the donor renal artery to the recipient's external iliac artery as well as the donor ureter to the recipient's bladder. After removing the clamps on the external iliac artery, the recipient's blood is allowed to perfuse the transplanted kidney. Within 3 minutes, the surgeon notes that the kidney does not appear to be sufficiently perfused. Upon further investigation, an inflammatory reaction is noted that led to clotting off of the donor renal artery, preventing blood flow to the transplanted organ. Which of the following best describes the pathophysiology of this complication? Tested Concept QID: 106676 Type & Select Correct Answer 1 Type I hypersensitivity reaction 7% (3/44) 2 Type II hypersensitivity reaction 68% (30/44) 3 Type III hypersensitivity reaction 5% (2/44) 4 Type IV hypersensitivity reaction 5% (2/44) 5 Graft-versus-host disease 16% (7/44) M 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (M1.IM.14.76) A 62-year-old female with a history of uncontrolled hypertension undergoes kidney transplantation. One month following surgery she has elevated serum blood urea nitrogen and creatinine and the patient complains of fever and arthralgia. Her medications include tacrolimus and prednisone. If the patient were experiencing acute, cell-mediated rejection, which of the following would you most expect to see upon biopsy of the transplanted kidney? Tested Concept QID: 101030 Type & Select Correct Answer 1 Sloughing of proximal tubular epithelial cells 5% (4/73) 2 Lymphocytic infiltrate of the tubules and interstitium 70% (51/73) 3 Drug precipitation in the renal tubules 7% (5/73) 4 Granular immunofluorescence around the glomerular basement membrane 11% (8/73) 5 Crescent formation in Bowman’s space 4% (3/73) M 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.IM.13.52) Several weeks following a kidney transplantation, a 50-year-old Caucasian female presents for evaluation of the transplanted organ. Biopsy shows inflammation involving the endothelial cells of the kidney vasculature and the presence of mononuclear cells in the interstitium. Which of the following are most likely responsible for this presentation? Tested Concept QID: 100473 Type & Select Correct Answer 1 Donor T-cells 16% (50/312) 2 Recipient T-cells 60% (188/312) 3 Preformed recipient antibodies 10% (30/312) 4 Donor antibodies 4% (11/312) 5 Deposition of antibody immune complexes 7% (23/312) M 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (M1.IM.13.77) A physician is describing a case to his residents where a kidney transplant was rapidly rejected by the recipient minutes after graft perfusion. The physician most likely describes all of the following manifestations EXCEPT? Tested Concept QID: 100498 Type & Select Correct Answer 1 Graft mottling 6% (7/113) 2 Graft cyanosis 4% (4/113) 3 Low urine output with evidence of blood 15% (17/113) 4 Histological evidence of arteriosclerosis 71% (80/113) 5 Histological evidence of vascular damage 1% (1/113) M 4 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (M1.IM.13.18) A 32-year-old Caucasian female required a kidney transplant 3 years ago. She presents with elevated creatinine levels (2.6 mg/dl) and an elevated blood pressure (160/90 mmHg). A biopsy is taken of the transplanted kidney. Following histological findings, a diagnosis of chronic graft rejection is made. Which of the following is NOT a likely finding? Tested Concept QID: 100439 Type & Select Correct Answer 1 Interstitial fibrosis 5% (14/265) 2 Glomerular destruction 6% (17/265) 3 Tubular atrophy 11% (30/265) 4 Graft arteriosclerosis 14% (37/265) 5 Glomerular crescents 62% (164/265) M 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (M1.IM.13.42) A 40-year-old male with a history of chronic alcoholism recently received a liver transplant. Two weeks following the transplant, the patient presents with a skin rash and frequent episodes of bloody diarrhea. A colonoscopy is performed and biopsy reveals apoptosis of colonic epithelial cells. What is most likely mediating these symptoms? Tested Concept QID: 100463 Type & Select Correct Answer 1 Donor T-cells 59% (42/71) 2 Recipient T-cells 14% (10/71) 3 Donor B-cells 8% (6/71) 4 Recipient B-cells 3% (2/71) 5 Recipient antibodies 11% (8/71) M 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept