Comprehensive Assessment of Pre-Transplant Candidate Selection & Optimization,
Peritransplant Surgical & Immunosuppression Management, and Post-Transplant Long-
Term Graft Function & Complication Prevention in Solid Organ Transplantation
Difficulty: Mixed (Advanced / Hard / Scenario-driven)
Target Audience: Experienced clinical transplant nurses, CCTN candidates, and advanced practitioners
Section 1: Pre-Transplant Evaluation & Listing (Questions 1–30)
1. A 54-year-old with nonalcoholic steatohepatitis (NASH) cirrhosis is being evaluated for liver transplant. Which
finding is a relative contraindication to isolated liver transplantation?
A) BMI 34 with well-controlled diabetes
B) Hepatocellular carcinoma (HCC) within Milan criteria
C) Severe portopulmonary hypertension (mPAP 55 mmHg)
D) Hepatic encephalopathy refractory to lactulose
Correct Answer: C
*Rationale: Severe portopulmonary hypertension (mPAP >50 mmHg) is associated with high perioperative mortality
and may require combined heart-lung-liver or be a contraindication unless reversible.*
2. What is the minimum acceptable calculated creatinine clearance (CrCl) for a solitary kidney transplant candidate
without combined organ disease?
A) <10 mL/min
B) 10–20 mL/min
C) 21–30 mL/min
D) >30 mL/min
Correct Answer: B
*Rationale: Most centers list for kidney transplant when CrCl is ≤20 mL/min (or eGFR <20) unless diabetic or rapidly
declining.*
3. Which vaccine is contraindicated in a pre-lung transplant candidate with severe COPD?
A) Inactivated influenza
B) Pneumococcal polysaccharide (PPSV23)
C) Live attenuated zoster (Zostavax)
D) SARS-CoV-2 mRNA vaccine
Correct Answer: C
Rationale: Live vaccines are contraindicated pre-transplant due to post-transplant
immunosuppression; recombinant zoster (Shingrix) is preferred.
4. A candidate with polycystic kidney disease (PKD) is being evaluated. Which additional pre-transplant study is
essential?
A) Routine cardiac PET scan
B) Screening for cerebral aneurysms
C) Serum alpha-fetoprotein (AFP)
D) Bone marrow biopsy
Correct Answer: B
,Rationale: PKD patients have higher risk of cerebral aneurysms; screening with MRA is
recommended before transplant.
5. Which psychosocial factor most strongly predicts poor post-transplant adherence?
A) History of depression treated with SSRI
B) Missing >3 pre-transplant clinic appointments
C) Living alone but with strong family support
D) Prior successful kidney transplant 10 years ago
Correct Answer: B
Rationale: Missed appointments correlate with non-adherence; pre-transplant
behavioral patterns often persist post-transplant.
6. A patient with alcohol-associated liver disease has completed 6 months of abstinence. What additional pre-
transplant requirement is often mandated?
A) Liver biopsy showing no active inflammation
B) Random urine toxicology screen negative for all substances
C) Formal psychosocial evaluation with relapse risk assessment
D) MELD-Na score <15
Correct Answer: C
Rationale: Psychosocial evaluation and commitment to sobriety are required; many
programs use multidisciplinary team judgment.
7. In a heart transplant candidate with amyloidosis, which pre-transplant workup is critical?
A) Endomyocardial biopsy to rule out active myocarditis
B) Serum and urine immunofixation with cardiac MRI
C) Coronary angiography
D) Right heart catheterization with vasodilator challenge
Correct Answer: B
Rationale: Amyloidosis recurrence is high; screening for light chain involvement and
cardiac involvement guides listing for combined heart-stem cell transplant.
8. What is the recommended interval for repeat HLA antibody screening in a sensitized patient awaiting kidney
transplant?
A) Every 6 months if stable
B) Monthly
C) Only at time of deceased donor offer
D) Annually
Correct Answer: B
*Rationale: Sensitized patients should have PRA/ DSA checked monthly or at least every 3 months, but monthly is
preferred to catch changes.*
9. Which recipient factor most increases the risk of primary graft non-function (PNF) after liver transplant?
A) MELD score 28
B) Pretransplant vasopressor requirement
,C) Donor age 55
D) Recipient BMI 30
Correct Answer: B
Rationale: Hemodynamic instability with vasopressors pre-transplant indicates poor
recipient reserve and increases PNF risk.
10. A 32-year-old with cystic fibrosis (CF) is being evaluated for lung transplant. Which extrapulmonary manifestation
requires specific pre-transplant intervention?
A) Pancreatic insufficiency
B) CF-related diabetes (CFRD)
C) Sinus disease
D) Distal intestinal obstruction syndrome (DIOS)
Correct Answer: B
Rationale: CFRD requires intensive glycemic control pre-transplant to reduce post-
transplant infection and mortality.
11. What absolute value of pulmonary artery systolic pressure (PASP) precludes isolated kidney transplant?
A) >25 mmHg
B) >35 mmHg
C) >50 mmHg
D) >70 mmHg
Correct Answer: C
*Rationale: PASP >50-60 mmHg suggests significant pulmonary hypertension; combined kidney-lung or heart-kidney
may be considered.*
12. Which pre-transplant malignancy requires a 5-year disease-free interval before listing (except certain low-risk
cases)?
A) Resected basal cell carcinoma
B) In situ cervical cancer
C) Melanoma >1 mm Breslow depth
D) Incidental renal cell carcinoma <2 cm
Correct Answer: C
*Rationale: Higher-risk melanoma requires 5 years; low-risk BCC, SCC in situ, incidental RCC <2cm may have shorter
intervals.*
13. A pre-kidney transplant candidate has a CPRA of 99.9%. Which strategy best improves transplant access?
A) Accept any deceased donor offer regardless of HLA match
B) Enroll in a paired exchange or participate in a desensitization protocol
C) Avoid all blood transfusions
D) List only for a living donor with identical HLA
Correct Answer: B
Rationale: Highly sensitized patients need desensitization (IVIG, plasmapheresis) or
paired exchange programs.
14. In liver transplant candidates, which cardiac finding is an absolute contraindication?
, A) Left ventricular ejection fraction 35%
B) Untreated coronary artery disease with inducible ischemia
C) Mild aortic stenosis
D) Atrial fibrillation on apixaban
Correct Answer: B
Rationale: Uncorrected significant CAD is a contraindication; must be treated before or
combined with liver transplant.
15. What is the goal hemoglobin A1c (HbA1c) for a diabetic kidney transplant candidate?
A) <6.0%
B) <7.0%
C) <8.5%
D) No goal, diabetes is not a risk factor
Correct Answer: B
*Rationale: Target <7.0% to reduce perioperative complications and post-transplant infections.*
16. A candidate for pancreas transplant alone (PTA) must have which of the following?
A) Type 2 diabetes with BMI >35
B) History of recurrent severe hypoglycemia despite expert management
C) eGFR >60 mL/min
D) Positive C-peptide
Correct Answer: B
Rationale: PTA is indicated for brittle type 1 diabetes with severe hypoglycemia
unawareness; eGFR must be preserved.
17. Which pulmonary function test (PFT) parameter is a relative contraindication for lung transplant?
A) FEV1 25% predicted
B) FVC 45% predicted
C) DLCO 20% predicted
D) FEV1/FVC ratio 0.7
Correct Answer: C
*Rationale: Very low DLCO (<20-25%) may indicate poor pulmonary vascular bed; but not absolute; depends on
diagnosis.*
18. Pre-transplant nutritional goal for a malnourished liver candidate (BMI 17) is:
A) Achieve BMI >30 before listing
B) Initiate enteral or parenteral nutrition to improve prealbumin >15 mg/dL
C) Avoid any nutrition support to reduce infection risk
D) Restrict protein to 0.5 g/kg/day
Correct Answer: B
*Rationale: Optimize nutrition; prealbumin >15 mg/dL or albumin >3.0 g/dL preferred before transplant.*
19. Which pre-transplant infection must be treated before listing for solid organ transplant?
A) Latent tuberculosis (positive IGRA)
B) Asymptomatic bacteriuria
Peritransplant Surgical & Immunosuppression Management, and Post-Transplant Long-
Term Graft Function & Complication Prevention in Solid Organ Transplantation
Difficulty: Mixed (Advanced / Hard / Scenario-driven)
Target Audience: Experienced clinical transplant nurses, CCTN candidates, and advanced practitioners
Section 1: Pre-Transplant Evaluation & Listing (Questions 1–30)
1. A 54-year-old with nonalcoholic steatohepatitis (NASH) cirrhosis is being evaluated for liver transplant. Which
finding is a relative contraindication to isolated liver transplantation?
A) BMI 34 with well-controlled diabetes
B) Hepatocellular carcinoma (HCC) within Milan criteria
C) Severe portopulmonary hypertension (mPAP 55 mmHg)
D) Hepatic encephalopathy refractory to lactulose
Correct Answer: C
*Rationale: Severe portopulmonary hypertension (mPAP >50 mmHg) is associated with high perioperative mortality
and may require combined heart-lung-liver or be a contraindication unless reversible.*
2. What is the minimum acceptable calculated creatinine clearance (CrCl) for a solitary kidney transplant candidate
without combined organ disease?
A) <10 mL/min
B) 10–20 mL/min
C) 21–30 mL/min
D) >30 mL/min
Correct Answer: B
*Rationale: Most centers list for kidney transplant when CrCl is ≤20 mL/min (or eGFR <20) unless diabetic or rapidly
declining.*
3. Which vaccine is contraindicated in a pre-lung transplant candidate with severe COPD?
A) Inactivated influenza
B) Pneumococcal polysaccharide (PPSV23)
C) Live attenuated zoster (Zostavax)
D) SARS-CoV-2 mRNA vaccine
Correct Answer: C
Rationale: Live vaccines are contraindicated pre-transplant due to post-transplant
immunosuppression; recombinant zoster (Shingrix) is preferred.
4. A candidate with polycystic kidney disease (PKD) is being evaluated. Which additional pre-transplant study is
essential?
A) Routine cardiac PET scan
B) Screening for cerebral aneurysms
C) Serum alpha-fetoprotein (AFP)
D) Bone marrow biopsy
Correct Answer: B
,Rationale: PKD patients have higher risk of cerebral aneurysms; screening with MRA is
recommended before transplant.
5. Which psychosocial factor most strongly predicts poor post-transplant adherence?
A) History of depression treated with SSRI
B) Missing >3 pre-transplant clinic appointments
C) Living alone but with strong family support
D) Prior successful kidney transplant 10 years ago
Correct Answer: B
Rationale: Missed appointments correlate with non-adherence; pre-transplant
behavioral patterns often persist post-transplant.
6. A patient with alcohol-associated liver disease has completed 6 months of abstinence. What additional pre-
transplant requirement is often mandated?
A) Liver biopsy showing no active inflammation
B) Random urine toxicology screen negative for all substances
C) Formal psychosocial evaluation with relapse risk assessment
D) MELD-Na score <15
Correct Answer: C
Rationale: Psychosocial evaluation and commitment to sobriety are required; many
programs use multidisciplinary team judgment.
7. In a heart transplant candidate with amyloidosis, which pre-transplant workup is critical?
A) Endomyocardial biopsy to rule out active myocarditis
B) Serum and urine immunofixation with cardiac MRI
C) Coronary angiography
D) Right heart catheterization with vasodilator challenge
Correct Answer: B
Rationale: Amyloidosis recurrence is high; screening for light chain involvement and
cardiac involvement guides listing for combined heart-stem cell transplant.
8. What is the recommended interval for repeat HLA antibody screening in a sensitized patient awaiting kidney
transplant?
A) Every 6 months if stable
B) Monthly
C) Only at time of deceased donor offer
D) Annually
Correct Answer: B
*Rationale: Sensitized patients should have PRA/ DSA checked monthly or at least every 3 months, but monthly is
preferred to catch changes.*
9. Which recipient factor most increases the risk of primary graft non-function (PNF) after liver transplant?
A) MELD score 28
B) Pretransplant vasopressor requirement
,C) Donor age 55
D) Recipient BMI 30
Correct Answer: B
Rationale: Hemodynamic instability with vasopressors pre-transplant indicates poor
recipient reserve and increases PNF risk.
10. A 32-year-old with cystic fibrosis (CF) is being evaluated for lung transplant. Which extrapulmonary manifestation
requires specific pre-transplant intervention?
A) Pancreatic insufficiency
B) CF-related diabetes (CFRD)
C) Sinus disease
D) Distal intestinal obstruction syndrome (DIOS)
Correct Answer: B
Rationale: CFRD requires intensive glycemic control pre-transplant to reduce post-
transplant infection and mortality.
11. What absolute value of pulmonary artery systolic pressure (PASP) precludes isolated kidney transplant?
A) >25 mmHg
B) >35 mmHg
C) >50 mmHg
D) >70 mmHg
Correct Answer: C
*Rationale: PASP >50-60 mmHg suggests significant pulmonary hypertension; combined kidney-lung or heart-kidney
may be considered.*
12. Which pre-transplant malignancy requires a 5-year disease-free interval before listing (except certain low-risk
cases)?
A) Resected basal cell carcinoma
B) In situ cervical cancer
C) Melanoma >1 mm Breslow depth
D) Incidental renal cell carcinoma <2 cm
Correct Answer: C
*Rationale: Higher-risk melanoma requires 5 years; low-risk BCC, SCC in situ, incidental RCC <2cm may have shorter
intervals.*
13. A pre-kidney transplant candidate has a CPRA of 99.9%. Which strategy best improves transplant access?
A) Accept any deceased donor offer regardless of HLA match
B) Enroll in a paired exchange or participate in a desensitization protocol
C) Avoid all blood transfusions
D) List only for a living donor with identical HLA
Correct Answer: B
Rationale: Highly sensitized patients need desensitization (IVIG, plasmapheresis) or
paired exchange programs.
14. In liver transplant candidates, which cardiac finding is an absolute contraindication?
, A) Left ventricular ejection fraction 35%
B) Untreated coronary artery disease with inducible ischemia
C) Mild aortic stenosis
D) Atrial fibrillation on apixaban
Correct Answer: B
Rationale: Uncorrected significant CAD is a contraindication; must be treated before or
combined with liver transplant.
15. What is the goal hemoglobin A1c (HbA1c) for a diabetic kidney transplant candidate?
A) <6.0%
B) <7.0%
C) <8.5%
D) No goal, diabetes is not a risk factor
Correct Answer: B
*Rationale: Target <7.0% to reduce perioperative complications and post-transplant infections.*
16. A candidate for pancreas transplant alone (PTA) must have which of the following?
A) Type 2 diabetes with BMI >35
B) History of recurrent severe hypoglycemia despite expert management
C) eGFR >60 mL/min
D) Positive C-peptide
Correct Answer: B
Rationale: PTA is indicated for brittle type 1 diabetes with severe hypoglycemia
unawareness; eGFR must be preserved.
17. Which pulmonary function test (PFT) parameter is a relative contraindication for lung transplant?
A) FEV1 25% predicted
B) FVC 45% predicted
C) DLCO 20% predicted
D) FEV1/FVC ratio 0.7
Correct Answer: C
*Rationale: Very low DLCO (<20-25%) may indicate poor pulmonary vascular bed; but not absolute; depends on
diagnosis.*
18. Pre-transplant nutritional goal for a malnourished liver candidate (BMI 17) is:
A) Achieve BMI >30 before listing
B) Initiate enteral or parenteral nutrition to improve prealbumin >15 mg/dL
C) Avoid any nutrition support to reduce infection risk
D) Restrict protein to 0.5 g/kg/day
Correct Answer: B
*Rationale: Optimize nutrition; prealbumin >15 mg/dL or albumin >3.0 g/dL preferred before transplant.*
19. Which pre-transplant infection must be treated before listing for solid organ transplant?
A) Latent tuberculosis (positive IGRA)
B) Asymptomatic bacteriuria
