MCQ Quiz: Transplant

Solid organ transplantation is a life-saving intervention that necessitates a complex and lifelong commitment to immunosuppressive pharmacotherapy. The pharmacist’s role in managing these high-risk medications is crucial to navigating the delicate balance between preventing allograft rejection and minimizing the significant risks of infection, malignancy, and drug-related toxicities. A deep understanding of induction and maintenance immunosuppression, therapeutic drug monitoring, drug interactions, and opportunistic infection prophylaxis is essential. This quiz is designed for PharmD students to test their clinical knowledge on the intricate pharmacotherapy used in solid organ transplant recipients.

1. The primary goal of immunosuppressive therapy in solid organ transplantation is to prevent:

• a) The recipient’s immune system from attacking the transplanted organ (allograft).
• b) The transplanted organ from attacking the recipient’s body.
• c) All types of infections post-transplant.
• d) The development of hypertension.

Answer: a) The recipient’s immune system from attacking the transplanted organ (allograft).

2. Which of the following describes hyperacute rejection?

• a) A cell-mediated process that occurs weeks to months after transplant.
• b) A slow, chronic scarring of the organ that occurs over years.
• c) A T-cell mediated response to the graft.
• d) An immediate, antibody-mediated response to pre-formed antibodies, occurring within minutes to hours of transplant.

Answer: d) An immediate, antibody-mediated response to pre-formed antibodies, occurring within minutes to hours of transplant.

3. Basiliximab (Simulect®) is a monoclonal antibody used for induction therapy that works by:

• a) Depleting T-cells from the circulation.
• b) Blocking the interleukin-2 (IL-2) receptor on activated T-cells.
• c) Inhibiting calcineurin.
• d) Blocking DNA synthesis.

Answer: b) Blocking the interleukin-2 (IL-2) receptor on activated T-cells.

4. Antithymocyte globulin (Thymoglobulin®) is a polyclonal antibody that causes profound T-cell depletion. Due to the high risk of infusion-related reactions, what pre-medications are typically administered?

• a) An antacid and a stool softener.
• b) A corticosteroid, an antihistamine, and acetaminophen.
• c) An antibiotic and an antiviral.
• d) A statin and aspirin.

Answer: b) A corticosteroid, an antihistamine, and acetaminophen.

5. Tacrolimus and cyclosporine are the cornerstones of maintenance immunosuppression. They belong to which drug class?

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

Answer: d) Calcineurin inhibitors (CNIs)

6. What is the mechanism of action of calcineurin inhibitors?

• a) They block the co-stimulatory signal required for T-cell activation.
• b) They inhibit T-cell proliferation by blocking IL-2 production.
• c) They inhibit purine synthesis, preventing lymphocyte proliferation.
• d) They bind to mTOR, inhibiting cell growth and proliferation.

Answer: b) They inhibit T-cell proliferation by blocking IL-2 production.

7. A significant and dose-limiting toxicity common to both tacrolimus and cyclosporine is:

• a) Hepatotoxicity
• b) Nephrotoxicity
• c) Pulmonary fibrosis
• d) Bone marrow suppression

Answer: b) Nephrotoxicity

8. Mycophenolate mofetil (CellCept®) and mycophenolic acid (Myfortic®) work by inhibiting which enzyme, thereby blocking purine synthesis in lymphocytes?

• a) Calcineurin
• b) mTOR
• c) Inosine monophosphate dehydrogenase (IMPDH)
• d) Dihydrofolate reductase

Answer: c) Inosine monophosphate dehydrogenase (IMPDH)

9. The most common adverse effects associated with mycophenolate products are:

• a) Neurological (tremor, headache).
• b) Cardiovascular (hypertension, hyperlipidemia).
• c) Gastrointestinal (diarrhea, nausea, vomiting).
• d) Dermatological (hirsutism, gingival hyperplasia).

Answer: c) Gastrointestinal (diarrhea, nausea, vomiting).

10. Sirolimus and everolimus are classified as mTOR inhibitors. A characteristic adverse effect of this class that can be problematic in the early post-transplant period is:

• a) Rapid wound healing.
• b) Impaired wound healing.
• c) Severe hypertension.
• d) Hair growth.

Answer: b) Impaired wound healing.

11. A patient’s tacrolimus trough level comes back high. Which of the following could be a contributing factor?

• a) The patient started taking St. John’s Wort.
• b) The patient started taking carbamazepine.
• c) The patient started drinking grapefruit juice daily.
• d) The patient forgot to take their morning dose.

Answer: c) The patient started drinking grapefruit juice daily.

*12. A kidney transplant recipient who is positive for CYP3A5*1/1 (an extensive metabolizer) will likely require what kind of tacrolimus dose compared to a poor metabolizer (CYP3A53/3)?

• a) A lower starting dose.
• b) The same starting dose.
• c) A higher starting dose to achieve therapeutic levels.
• d) Tacrolimus is contraindicated in this patient.

Answer: c) A higher starting dose to achieve therapeutic levels.

13. All solid organ transplant recipients should receive prophylaxis for Pneumocystis jirovecii pneumonia (PJP) for at least 6-12 months post-transplant. What is the first-line agent for this?

• a) Azithromycin
• b) Trimethoprim-sulfamethoxazole (Bactrim)
• c) Fluconazole
• d) Valganciclovir

Answer: b) Trimethoprim-sulfamethoxazole (Bactrim)

14. A kidney transplant recipient is Donor CMV-positive / Recipient CMV-negative (D+/R-). This patient is at high risk for CMV infection and should receive prophylaxis with which agent?

• a) Acyclovir
• b) Valganciclovir
• c) Amoxicillin
• d) Itraconazole

Answer: b) Valganciclovir

15. Belatacept is a maintenance immunosuppressant that works by:

• a) Blocking the IL-2 receptor.
• b) Inhibiting calcineurin.
• c) Depleting B-cells.
• d) Blocking T-cell co-stimulation by binding to CD80 and CD86.

Answer: d) Blocking T-cell co-stimulation by binding to CD80 and CD86.

16. A patient on cyclosporine complains of swollen, tender gums and new hair growth on their face. These are characteristic side effects of which drug?

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

Answer: c) Cyclosporine

17. What is the purpose of therapeutic drug monitoring (TDM) for calcineurin inhibitors?

• a) To ensure drug levels are high enough to cause toxicity.
• b) To maintain drug concentrations within a target range that minimizes rejection risk while avoiding toxicity.
• c) It is only done to satisfy insurance requirements.
• d) To determine if the patient has a CYP3A5 polymorphism.

Answer: b) To maintain drug concentrations within a target range that minimizes rejection risk while avoiding toxicity.

18. A common long-term complication of chronic immunosuppression is:

• a) Reduced risk of cancer.
• b) Improved kidney function.
• c) An increased risk of malignancies, particularly skin cancer and PTLD.
• d) Lowered cholesterol levels.

Answer: c) An increased risk of malignancies, particularly skin cancer and PTLD.

19. A patient taking azathioprine should be screened for a deficiency in which enzyme to avoid life-threatening myelosuppression?

• a) CYP3A5
• b) UGT1A1
• c) Thiopurine methyltransferase (TPMT)
• d) G6PD

Answer: c) Thiopurine methyltransferase (TPMT)

20. A pharmacist is counseling a new kidney transplant recipient. A critical piece of education is:

• a) “You can stop taking these medications once you feel well.”
• b) “It is crucial to take your immunosuppressants exactly as prescribed for the life of your organ.”
• c) “These medications have no side effects.”
• d) “You should double your dose if you forget one.”

Answer: b) “It is crucial to take your immunosuppressants exactly as prescribed for the life of your organ.”

21. New-onset diabetes after transplantation (NODAT) is a well-known metabolic complication, particularly associated with which class of immunosuppressants?

• a) Antimetabolites like mycophenolate.
• b) mTOR inhibitors like sirolimus.
• c) Calcineurin inhibitors (especially tacrolimus) and corticosteroids.
• d) Induction antibodies like basiliximab.

Answer: c) Calcineurin inhibitors (especially tacrolimus) and corticosteroids.

22. Which of the following is a common drug that is a potent inhibitor of CYP3A4 and can dangerously increase tacrolimus levels?

• a) Rifampin
• b) Phenytoin
• c) St. John’s Wort
• d) Voriconazole

Answer: d) Voriconazole

23. High-dose intravenous corticosteroids are the first-line treatment for which type of rejection?

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

Answer: b) Acute cellular rejection

24. A patient is switched from mycophenolate mofetil (CellCept) to enteric-coated mycophenolic acid (Myfortic). Why is this switch typically made?

• a) To improve efficacy.
• b) To potentially reduce GI side effects.
• c) Because Myfortic has a longer half-life.
• d) Because Myfortic is less expensive.

Answer: b) To potentially reduce GI side effects.

25. A liver transplant recipient on tacrolimus should be counseled to avoid:

• a) Dairy products.
• b) Leafy green vegetables.
• c) Grapefruit and grapefruit juice.
• d) High-protein meals.

Answer: c) Grapefruit and grapefruit juice.

26. What is a key difference between depleting and non-depleting induction agents?

• a) Depleting agents (e.g., antithymocyte globulin) remove T-cells from circulation, while non-depleting agents do not.
• b) Non-depleting agents are more potent.
• c) Depleting agents have fewer side effects.
• d) Non-depleting agents require pre-medication.

Answer: a) Depleting agents (e.g., antithymocyte globulin) remove T-cells from circulation, while non-depleting agents do not.

27. A heart transplant recipient develops hyperlipidemia. Which immunosuppressant is most likely contributing to this?

• a) Mycophenolate
• b) Basiliximab
• c) Sirolimus or Cyclosporine
• d) Azathioprine

Answer: c) Sirolimus or Cyclosporine

28. What is the primary role of a transplant pharmacist on the multidisciplinary team?

• a) To perform the transplant surgery.
• b) To diagnose organ rejection via biopsy.
• c) To manage and optimize complex immunosuppressive and prophylactic medication regimens.
• d) To determine HLA matching.

Answer: c) To manage and optimize complex immunosuppressive and prophylactic medication regimens.

29. Antibody-mediated rejection is treated with therapies designed to remove or inhibit donor-specific antibodies (DSAs), such as:

• a) High-dose corticosteroids alone.
• b) Plasmapheresis and/or intravenous immune globulin (IVIG).
• c) Increased doses of mycophenolate.
• d) An mTOR inhibitor.

Answer: b) Plasmapheresis and/or intravenous immune globulin (IVIG).

30. Which type of vaccine should generally be avoided in solid organ transplant recipients?

• a) Inactivated influenza vaccine
• b) Pneumococcal vaccine
• c) Live attenuated vaccines (e.g., MMR, varicella)
• d) Tdap vaccine

Answer: c) Live attenuated vaccines (e.g., MMR, varicella)

31. A patient taking tacrolimus should have their trough level drawn:

• a) At a random time during the day.
• b) Immediately after their evening dose.
• c) Immediately before their morning dose.
• d) 4 hours after their morning dose.

Answer: c) Immediately before their morning dose.

32. Long-term use of corticosteroids is associated with which of the following adverse effects?

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

Answer: d) All of the above

33. The “triple therapy” backbone of maintenance immunosuppression typically consists of:

• a) An mTOR inhibitor, an antimetabolite, and a corticosteroid.
• b) A calcineurin inhibitor, an antimetabolite, and a corticosteroid.
• c) A calcineurin inhibitor, an mTOR inhibitor, and an antimetabolite.
• d) Three different calcineurin inhibitors.

Answer: b) A calcineurin inhibitor, an antimetabolite, and a corticosteroid.

34. Post-transplant lymphoproliferative disorder (PTLD) is a type of malignancy that is strongly associated with which virus?

• a) Cytomegalovirus (CMV)
• b) Epstein-Barr virus (EBV)
• c) Hepatitis B virus (HBV)
• d) Human immunodeficiency virus (HIV)

Answer: b) Epstein-Barr virus (EBV)

35. A patient on cyclosporine should have their blood pressure monitored closely because it frequently causes:

• a) Hypotension
• b) Postural hypotension
• c) Hypertension
• d) No change in blood pressure

Answer: c) Hypertension

36. Belatacept is contraindicated in which patient population due to an increased risk of PTLD?

• a) Patients who are EBV-seropositive.
• b) Patients who are EBV-seronegative.
• c) Patients with diabetes.
• d) Patients over the age of 65.

Answer: b) Patients who are EBV-seronegative.

37. Compared to tacrolimus, cyclosporine is more likely to cause which cosmetic side effects?

• a) Alopecia and tremor
• b) Diarrhea and nausea
• c) Hirsutism and gingival hyperplasia
• d) Acne and weight loss

Answer: c) Hirsutism and gingival hyperplasia

38. A patient is prescribed valganciclovir for CMV prophylaxis. The pharmacist must ensure the dose is adjusted based on the patient’s:

• a) Liver function
• b) Body weight
• c) Renal function
• d) Age

Answer: c) Renal function

39. Tacrolimus is available in immediate-release (IR) and extended-release (ER) formulations. The total daily doses are generally the same, but the frequency is different. What are the typical frequencies?

• a) IR is once daily, ER is twice daily.
• b) IR is twice daily, ER is once daily.
• c) Both are taken four times daily.
• d) Both are taken once weekly.

Answer: b) IR is twice daily, ER is once daily.

40. A patient on high-dose immunosuppression develops a fever. This should be considered a sign of what until proven otherwise?

• a) A normal response.
• b) An infection.
• c) Organ rejection.
• d) An infusion reaction.

Answer: b) An infection.

41. Which of the following is NOT a goal of induction therapy?

• a) To provide intense initial immunosuppression to prevent early acute rejection.
• b) To allow for the delay or reduction of maintenance immunosuppressants.
• c) To completely eliminate the need for lifelong maintenance therapy.
• d) To target activated T-cells during the time of highest antigenic stimulation.

Answer: c) To completely eliminate the need for lifelong maintenance therapy.

42. Why should a patient on a CNI avoid potassium supplements and potassium-sparing diuretics unless directed by their team?

• a) CNIs cause severe hypokalemia.
• b) CNIs can cause hyperkalemia.
• c) CNIs interact with potassium to form a precipitate.
• d) Potassium supplements decrease CNI absorption.

Answer: b) CNIs can cause hyperkalemia.

43. A common monitoring parameter for a patient taking sirolimus or everolimus is a:

• a) Lipid panel
• b) Serum iron level
• c) Liver function test
• d) Complete blood count

Answer: a) Lipid panel

44. A patient taking mycophenolate should be counseled to:

• a) Take it on an empty stomach to maximize absorption, but with food if GI upset occurs.
• b) Always take it with an antacid.
• c) Crush the tablets for easier swallowing.
• d) Take it only when they feel signs of rejection.

Answer: a) Take it on an empty stomach to maximize absorption, but with food if GI upset occurs.

45. Which of the following is a major reason for medication non-adherence in transplant recipients?

• a) The complexity of the regimen and side effect burden.
• b) The low cost of the medications.
• c) The lack of perceived benefit.
• d) The once-daily dosing of all medications.

Answer: a) The complexity of the regimen and side effect burden.

46. A patient on tacrolimus develops tremors and a headache. The pharmacist recognizes this as a sign of:

• a) Rejection
• b) Infection
• c) CNI-related neurotoxicity
• d) An allergic reaction

Answer: c) CNI-related neurotoxicity

47. BK virus is an opportunistic pathogen that can cause nephropathy and graft loss in which type of transplant recipient?

• a) Liver
• b) Heart
• c) Lung
• d) Kidney

Answer: d) Kidney

48. In the context of transplantation, “HLA” stands for:

• a) High Level Antibody
• b) Human Leukocyte Antigen
• c) Hepatic Limiting Agent
• d) Heart-Lung Allocation

Answer: b) Human Leukocyte Antigen

49. A patient is concerned about the cost of their immunosuppressants. An important role for the transplant pharmacist is to:

• a) Tell the patient they must find a way to pay for it.
• b) Explore patient assistance programs and help find the most cost-effective regimen.
• c) Switch all medications to over-the-counter alternatives.
• d) Discontinue the therapy.

Answer: b) Explore patient assistance programs and help find the most cost-effective regimen.

50. The ultimate goal of managing a transplant recipient’s medication regimen is to:

• a) Use the highest doses possible of all drugs.
• b) Use the fewest number of drugs possible.
• c) Individualize therapy to maximize long-term patient and allograft survival.
• d) Ensure the patient never gets sick.

Answer: c) Individualize therapy to maximize long-term patient and allograft survival.