MCQ Quiz: Introduction to Transplantation

Solid organ transplantation is a transformative medical procedure that offers a new lease on life to patients with end-stage organ failure. The success of a transplant, however, hinges on a lifelong balancing act: suppressing the body’s natural immune system to prevent organ rejection while minimizing the risks of infection and drug toxicity. This introductory quiz is designed for PharmD students to build a foundational understanding of transplant immunology, the types of graft rejection, and the cornerstone pharmacotherapy used for induction and maintenance immunosuppression. Mastering these principles is the first step toward competently caring for this complex and vulnerable patient population.

1. A kidney transplanted from one human to another is an example of an:

• a) Autograft
• b) Isograft
• c) Allograft
• d) Xenograft

Answer: c) Allograft

2. Which type of rejection occurs within minutes to hours after transplantation and is caused by pre-existing antibodies in the recipient against donor antigens?

• a) Hyperacute rejection
• b) Acute cellular rejection
• c) Chronic rejection
• d) Antibody-mediated rejection

Answer: a) Hyperacute rejection

3. The primary immune cells responsible for mediating acute cellular rejection are:

• a) Neutrophils
• b) B-lymphocytes
• c) T-lymphocytes
• d) Basophils

Answer: c) T-lymphocytes

4. The “three-signal model” of T-cell activation is a fundamental concept in transplant immunology. Signal 1 involves the T-cell receptor recognizing a specific antigen presented by:

• a) An antigen-presenting cell (APC) via the MHC complex.
• b) A B-cell.
• c) A natural killer (NK) cell.
• d) The IL-2 receptor.

Answer: a) An antigen-presenting cell (APC) via the MHC complex.

5. What is the primary purpose of Human Leukocyte Antigen (HLA) matching in solid organ transplantation?

• a) To ensure the organ is the correct size.
• b) To reduce the risk of organ rejection by matching immune system proteins between donor and recipient.
• c) To determine the patient’s blood type.
• d) To screen for infectious diseases.

Answer: b) To reduce the risk of organ rejection by matching immune system proteins between donor and recipient.

6. Induction immunosuppression is given at the time of transplantation to:

• a) Provide long-term, low-level immunosuppression.
• b) Treat chronic rejection.
• c) Provide intense, potent immunosuppression to prevent early acute rejection.
• d) Eliminate the need for any future immunosuppressant medications.

Answer: c) Provide intense, potent immunosuppression to prevent early acute rejection.

7. Basiliximab (Simulect®) is a non-depleting monoclonal antibody used for induction that targets what receptor on T-cells?

• a) CD3 receptor
• b) CD20 receptor
• c) IL-2 receptor (CD25)
• d) TNF-alpha receptor

Answer: c) IL-2 receptor (CD25)

8. Antithymocyte globulin (Thymoglobulin®) is considered a T-cell depleting induction agent. This means it:

• a) Temporarily blocks T-cell function.
• b) Causes the removal and destruction of T-cells from circulation.
• c) Only targets B-cells.
• d) Prevents the production of new T-cells.

Answer: b) Causes the removal and destruction of T-cells from circulation.

9. Due to the risk of cytokine release syndrome, patients receiving their first dose of antithymocyte globulin are typically pre-medicated with:

• a) An antibiotic and an antiviral.
• b) A statin and aspirin.
• c) Acetaminophen, diphenhydramine, and a corticosteroid.
• d) An antacid and loperamide.

Answer: c) Acetaminophen, diphenhydramine, and a corticosteroid.

10. What is the cornerstone medication class for most maintenance immunosuppression regimens?

• a) mTOR inhibitors
• b) Corticosteroids
• c) Calcineurin inhibitors (CNIs)
• d) Antimetabolites

Answer: c) Calcineurin inhibitors (CNIs)

11. Tacrolimus and cyclosporine are examples of:

• a) Antimetabolites
• b) Polyclonal antibodies
• c) Calcineurin inhibitors
• d) mTOR inhibitors

Answer: c) Calcineurin inhibitors

12. The mechanism of action of calcineurin inhibitors like tacrolimus involves:

• a) Blocking the IL-2 receptor.
• b) Inhibiting the production of IL-2, a key cytokine for T-cell proliferation.
• c) Blocking DNA synthesis in lymphocytes.
• d) Depleting circulating T-cells.

Answer: b) Inhibiting the production of IL-2, a key cytokine for T-cell proliferation.

13. A patient is maintained on a “triple therapy” immunosuppression regimen. This most commonly includes a CNI, an antimetabolite, and which other agent?

• a) An mTOR inhibitor
• b) An induction agent
• c) A corticosteroid (e.g., prednisone)
• d) A monoclonal antibody

Answer: c) A corticosteroid (e.g., prednisone)

14. Mycophenolate mofetil is an antimetabolite that works by inhibiting which enzyme crucial for lymphocyte proliferation?

• a) Calcineurin
• b) Xanthine oxidase
• c) HMG-CoA reductase
• d) Inosine monophosphate dehydrogenase (IMPDH)

Answer: d) Inosine monophosphate dehydrogenase (IMPDH)

15. A major reason for using therapeutic drug monitoring (TDM) for tacrolimus is its:

• a) Wide therapeutic index.
• b) Lack of side effects.
• c) Narrow therapeutic index and high inter-patient variability.
• d) Once-weekly dosing schedule.

Answer: c) Narrow therapeutic index and high inter-patient variability.

16. Acute rejection most commonly occurs within what timeframe post-transplant?

• a) The first few minutes.
• b) The first few weeks to months.
• c) 5-10 years post-transplant.
• d) It can only occur immediately after surgery.

Answer: b) The first few weeks to months.

17. A patient on long-term immunosuppression is at an increased risk for:

• a) Opportunistic infections and malignancies.
• b) An overactive immune system.
• c) Autoimmune diseases.
• d) Fewer side effects over time.

Answer: a) Opportunistic infections and malignancies.

18. Azathioprine is an older antimetabolite. Patients must be screened for a deficiency in which enzyme to avoid severe myelosuppression?

• a) CYP3A4
• b) UGT1A1
• c) Thiopurine S-methyltransferase (TPMT)
• d) Aldehyde dehydrogenase

Answer: c) Thiopurine S-methyltransferase (TPMT)

19. Which of the following is a common long-term adverse effect of corticosteroid use?

• a) Osteoporosis
• b) Diabetes
• c) Weight gain
• d) All of the above

Answer: d) All of the above.

20. Sirolimus and everolimus are examples of which class of immunosuppressants?

• a) Calcineurin inhibitors
• b) Antimetabolites
• c) mTOR inhibitors
• d) Monoclonal antibodies

Answer: c) mTOR inhibitors

21. A critical counseling point for a patient taking cyclosporine (Neoral®/Gengraf®) is:

• a) The medication can be taken with or without food, but be consistent.
• b) Different brands of cyclosporine are not bioequivalent and should not be interchanged without consulting the transplant team.
• c) This medication often causes hair loss.
• d) There are no significant drug interactions to worry about.

Answer: b) Different brands of cyclosporine are not bioequivalent and should not be interchanged without consulting the transplant team.

22. A patient on tacrolimus should be counseled to avoid which fruit/juice due to a significant drug interaction that increases tacrolimus levels?

• a) Apple
• b) Orange
• c) Grape
• d) Grapefruit

Answer: d) Grapefruit

23. Which of the following is a primary role of the transplant pharmacist?

• a) Performing the organ procurement surgery.
• b) Educating patients on complex medication regimens and monitoring for adverse effects and interactions.
• c) Making the final decision on who receives an organ.
• d) Reading the organ biopsy slides.

Answer: b) Educating patients on complex medication regimens and monitoring for adverse effects and interactions.

24. Prophylaxis for Pneumocystis jirovecii pneumonia (PJP) is recommended for at least the first 6-12 months post-transplant. The drug of choice is:

• a) Dapsone
• b) Atovaquone
• c) Trimethoprim-sulfamethoxazole
• d) Inhaled pentamidine

Answer: c) Trimethoprim-sulfamethoxazole

25. Chronic allograft rejection is characterized by:

• a) A rapid increase in serum creatinine.
• b) A sudden onset of fever and graft tenderness.
• c) A slow, progressive decline in organ function and fibrosis.
• d) A positive blood culture.

Answer: c) A slow, progressive decline in organ function and fibrosis.

26. Which of the following is a common metabolic side effect of both tacrolimus and cyclosporine?

• a) Hypoglycemia
• b) Hyperglycemia (New Onset Diabetes After Transplant – NODAT)
• c) Weight loss
• d) Hypokalemia

Answer: b) Hyperglycemia (New Onset Diabetes After Transplant – NODAT)

27. The first step in treating an episode of acute cellular rejection is typically:

• a) An increase in the maintenance immunosuppression dose.
• b) A course of high-dose intravenous corticosteroids (pulse steroids).
• c) Initiation of plasmapheresis.
• d) Surgical removal of the organ.

Answer: b) A course of high-dose intravenous corticosteroids (pulse steroids).

28. A key difference between mycophenolate mofetil (CellCept®) and mycophenolic acid (Myfortic®) is that Myfortic is:

• a) A more potent formulation.
• b) A liquid formulation.
• c) An enteric-coated formulation designed to reduce GI side effects.
• d) A pro-drug of CellCept.

Answer: c) An enteric-coated formulation designed to reduce GI side effects.

29. What type of cancer are transplant patients at a particularly high risk for developing?

• a) Lung cancer
• b) Colon cancer
• c) Skin cancer (especially squamous cell carcinoma)
• d) Pancreatic cancer

Answer: c) Skin cancer (especially squamous cell carcinoma)

30. Which of the following is a common adverse effect of tacrolimus?

• a) Gingival hyperplasia
• b) Hirsutism
• c) Tremor and headache
• d) Increased uric acid

Answer: c) Tremor and headache

31. Prophylaxis against Cytomegalovirus (CMV) is particularly important for which donor (D)/recipient (R) serostatus pairing?

• a) D+/R+
• b) D-/R-
• c) D-/R+
• d) D+/R-

Answer: d) D+/R-

32. A patient on immunosuppressants should be counseled to:

• a) Stop taking them if they get a cold.
• b) Report any signs of infection, such as fever or chills, to their transplant team immediately.
• c) Share their medications with family members if they get sick.
• d) Take half of their dose to save money.

Answer: b) Report any signs of infection, such as fever or chills, to their transplant team immediately.

33. Belatacept is a newer maintenance immunosuppressant that must be administered via which route?

• a) Oral
• b) Subcutaneous
• c) Intramuscular
• d) Intravenous infusion

Answer: d) Intravenous infusion

34. The main advantage of basiliximab over antithymocyte globulin for induction is:

• a) It is much more potent.
• b) It causes T-cell depletion.
• c) It has a much lower incidence of infusion reactions and side effects.
• d) It can be given orally.

Answer: c) It has a much lower incidence of infusion reactions and side effects.

35. A “crossmatch” test is performed before transplant to detect:

• a) The donor’s blood type.
• b) The presence of pre-formed recipient antibodies against donor HLA antigens.
• c) The donor’s renal function.
• d) The presence of viral infections.

Answer: b) The presence of pre-formed recipient antibodies against donor HLA antigens.

36. Hypertension is a very common complication after kidney transplant and is often caused or exacerbated by which medication class?

• a) Antimetabolites
• b) mTOR inhibitors
• c) Calcineurin inhibitors
• d) Monoclonal antibodies

Answer: c) Calcineurin inhibitors

37. Which statement about vaccination in transplant candidates is correct?

• a) All vaccines are contraindicated before transplant.
• b) It is ideal to administer all necessary vaccines, especially live vaccines, before the transplant surgery.
• c) Vaccines are only given after the transplant.
• d) Only the flu shot is recommended pre-transplant.

Answer: b) It is ideal to administer all necessary vaccines, especially live vaccines, before the transplant surgery.

38. The primary mechanism of mTOR inhibitors like sirolimus involves:

• a) Blocking calcineurin activity.
• b) Inhibiting a kinase involved in cell growth, proliferation, and angiogenesis.
• c) Blocking purine synthesis.
• d) Antagonizing the IL-2 receptor.

Answer: b) Inhibiting a kinase involved in cell growth, proliferation, and angiogenesis.

39. A transplant pharmacist reviewing a patient’s profile notes a new prescription for diltiazem. This is a concern because diltiazem is a CYP3A4 inhibitor and will likely do what to the patient’s tacrolimus level?

• a) Decrease it
• b) Increase it
• c) Have no effect on it
• d) Cause it to fluctuate unpredictably

Answer: b) Increase it

40. The term “allograft” refers to a transplanted organ, tissue, or cells from:

• a) The patient’s own body.
• b) A genetically identical twin.
• a) A non-genetically identical individual of the same species.
• d) An individual of a different species.

Answer: a) A non-genetically identical individual of the same species.

41. Which maintenance immunosuppressant has a boxed warning for increased risk of embryo-fetal toxicity (teratogenicity)?

• a) Prednisone
• b) Tacrolimus
• c) Cyclosporine
• d) Mycophenolate

Answer: d) Mycophenolate

42. A Panel Reactive Antibody (PRA) test measures:

• a) The recipient’s level of pre-sensitization to a panel of common HLA antigens.
• b) The function of the transplanted kidney.
• c) The recipient’s white blood cell count.
• d) The concentration of tacrolimus in the blood.

Answer: a) The recipient’s level of pre-sensitization to a panel of common HLA antigens.

43. The primary reason for long-term immunosuppression after a transplant is that the:

• a) Body’s immune memory is short.
• b) Transplanted organ is always seen as foreign by the immune system.
• c) Risk of rejection is highest 10 years after transplant.
• d) Medications help the new organ function better.

Answer: b) The transplanted organ is always seen as foreign by the immune system.

44. Post-transplant lymphoproliferative disorder (PTLD) is a type of cancer that is most commonly associated with which virus?

• a) Cytomegalovirus (CMV)
• b) Hepatitis C Virus (HCV)
• c) Epstein-Barr Virus (EBV)
• d) Parvovirus B19

Answer: c) Epstein-Barr Virus (EBV)

45. A patient on azathioprine is started on allopurinol for gout. This is a major drug interaction because allopurinol inhibits xanthine oxidase, which is responsible for metabolizing azathioprine, leading to:

• a) Decreased azathioprine levels and risk of rejection.
• b) Increased azathioprine levels and risk of life-threatening myelosuppression.
• c) Increased allopurinol levels.
• d) No significant interaction.

Answer: b) Increased azathioprine levels and risk of life-threatening myelosuppression.

46. Which of the following is NOT a common goal of pre-transplant evaluation?

• a) To assess the candidate’s medical suitability for surgery.
• b) To screen for and treat any underlying infections.
• c) To evaluate the candidate’s psychosocial and financial support systems.
• d) To begin the induction immunosuppression regimen one month before surgery.

Answer: d) To begin the induction immunosuppression regimen one month before surgery.

47. Which of the following is a symptom of acute kidney rejection?

• a) Decreased serum creatinine and increased urine output.
• b) Increased serum creatinine, decreased urine output, and graft tenderness.
• c) Low blood pressure and weight loss.
• d) Normal lab values.

Answer: b) Increased serum creatinine, decreased urine output, and graft tenderness.

48. A “steroid-free” or “steroid-sparing” maintenance regimen is often desirable to:

• a) Increase the risk of rejection.
• b) Reduce the long-term side effects associated with corticosteroids.
• c) Make the regimen more complex.
• d) Increase the cost of therapy.

Answer: b) Reduce the long-term side effects associated with corticosteroids.

49. Adherence to the immunosuppressive regimen is most critical during which period post-transplant?

• a) Only in the first month.
• b) Only after the first year.
• c) It is critical for the entire life of the allograft.
• d) It is not as important as adherence to blood pressure medications.

Answer: c) It is critical for the entire life of the allograft.

50. What is the definition of a “deceased donor”?

• a) A living person who donates a kidney.
• b) A person who has been declared brain dead and whose organs are donated with consent.
• c) A person who donates blood.
• d) A person who donates bone marrow.

Answer: b) A person who has been declared brain dead and whose organs are donated with consent.