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P6_02 Nephrology III ACPE Test

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1. L.M. is a 42-year-old woman who received a living-related donor transplant 2 years ago. At herlatest visit, she had an elevated serum creatinine concentration (2.4 mg/dL from 0.9 mg/dL).

After kidney biopsy, the diagnosis made was moderate rejection. She was treated with acorticosteroid pulse followed by rabbit antithymocyte globulin. Which one of the followingpreventive care measures is most important for L.M. within the next 6 months?

(A) Pneumococcal vaccine.

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(B) Influenza vaccine.

(C) Routine cancer screenings.

(D) Bone mineral density screening.

2. Questions 2 and 3 pertain to the following case

M.P. is a 58-year-old man who received a kidney transplant 3 years ago from a deceased donor.

M.P. is currently receiving cyclosporine, mycophenolate mofetil, and prednisone. Hiscomorbidities include type 2 diabetes mellitus, hypertension, and coronary artery disease. After arise in his creatinine concentration from 1.9 mg/dL to 2.7 mg/dL and rise in proteinuria from 325mg/day to 1140 mg/day, a kidney biopsy was performed, revealing moderate chronic allograftnephropathy.

Which one of the following changes to the immunosuppression regimen is warranted based onthe information presented above?

(A) Change cyclosporine to sirolimus.

(B) Change cyclosporine to tacrolimus.

(C) Change mycophenolate mofetil to sirolimus.

(D) Discontinue cyclosporine; adding another drug is not necessary.

3. M.P.’s blood pressure was elevated during his biopsy admission and is 160/85 mm Hg at anoutpatient visit 1 week later; he currently takes metoprolol succinate 50 mg/day. Which one of the following interventions is most appropriate for managing M.P. ’s blood pressure?

(A) Titrate dose of metoprolol.

(B) Withdraw metoprolol and add lisinopril.

(C) Add nifedipine to current regimen.

(D) Add losartan to current regimen.

4. C.W. is a 38-year-old African-American man with kidney disease secondary to malignanthypertension who started on hemodialysis at age 18. He received his first kidney transplant in1999, but it failed due to acute rejection within 1 year. He received a second transplant in 2002,

has had no rejection episodes, and has been diagnosed with new -onset diabetes mellitus. C.W. iscurrently receiving tacrolimus (recent trough concentrations of 11–14 ng/mL), mycophenolatemofetil (2 g/day), and prednisone (5 mg/day). The attending nephrologist would like to modifythe patient’s immunosuppression regimen before starting an oral hypoglycemic or insulintherapy. Which one of the following is the best modification for C.W.?

(A) Taper and discontinue prednisone over 2 months.

(B) Switch tacrolimus to cyclosporine.

(C) Lower the target trough of tacrolimus.

(D) Lower the target trough of tacrolimus and taper prednisone to 2.5 mg/day.

5. K.M. is a 25-year-old woman who received a kidney transplant about 3 years ago and expressesher desire to have children. She had a mild rejection episode 6 months post -transplant and was

successfully treated with a corticosteroid pulse. Her current regimen consists of tacrolimus andmycophenolate mofetil. Based on current knowledge about pregnancy after transplantation,which one of the following changes to her immunosuppression regimen is most appropriate?

(A) Switch tacrolimus to cyclosporine.

(B) Switch mycophenolate mofetil to azathioprine.

(C) Switch mycophenolate mofetil to azathioprine and add prednisone.

(D) Switch tacrolimus to sirolimus.

6. Questions 6 and 7 pertain to the following case.

A.B. is a 56-year-old man who received a kidney transplant about 2 years ago. He is concernedabout having brittle bones and has recently had a DEXA scan, but the results are not available

yet. Laboratory values at this visit include bicarbonate 23 mEq/L, serum creatinine 1.6 mg/dL,calcium 9.9 mg/dL, phosphorus 2.2 mg/dL, and intact parathyroid hormone 202 pg/mL.

Which one of the following oral drugs is the best therapy for A.B. at this time?

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(A) Calcium carbonate.

(B) Calcitriol.

(C) Vitamin D3.

(D) Sodium bicarbonate.

7. A.B. returns to clinic 3 months later with the results of his DEXA scan, which shows that A.B. hasosteopenia. Laboratory values at this visit include bicarbonate 24 mEq/L, serum creatinine 1.3mg/dL, calcium 10.6 mg/dL, phosphorus 2.5 mg/dL, and intact parathyroid hormone 449 pg/mL.

Which one of the following therapies is most appropriate for A.B. at this time?

(A) Alendronate.

(B) Cinacalcet.

(C) Calcitonin.

(D) Testosterone.


S.A. is a 59-year-old woman with kidney disease from type 2 diabetes. She is 4 years post-transplantation, and despite lifestyle changes and atorvastatin 80 mg/day, her lipid profilereveals total cholesterol 240 mg/dL, low-density lipoprotein 138 mg/dL, high-density lipoprotein39 mg/dL, and triglycerides 212 mg/dL. Hemoglobin A1c is 10.2% and blood pressure is 138/92mm Hg. She currently takes cyclosporine (trough 248 ng/mL), mycophenolate mofetil 2 g/day,and prednisone 7.5 mg/day.

Which one of the following is the most appropriate way to modify her immunosuppressionregimen to improve the lipid profile?

(A) Switch cyclosporine to tacrolimus.

(B) Switch cyclosporine to sirolimus.

(C) Decrease dosages of cyclosporine and prednisone.

(D) Switch mycophenolate mofetil to azathioprine.

9. Six months later, S.A.’s lipid goals still have not reached target (total cholesterol 229 mg/dL, low -density lipoprotein 114 mg/dL, high-density lipoprotein 42 mg/dL, and triglycerides 235 mg/dL).

Which one of the following is the most appropriate drug therapy for the patient at this point?

(A) Add colesevelam.

(B) Add ezetimibe.

(C) Add nicotinic acid.

(D) Add gemfibrozil.

10. Questions 10–12 pertain to the following case.

S.K. is a 60-year-old man who received a kidney transplant 4 years ago. Current medical issuesinclude new onset diabetes mellitus, hypertension, coronary artery disease, tobacco use, and

body mass index of 33 kg/m2 .

At this time, which one of the following lifestyle changes would be most beneficial to his (and hiskidney’s) survival?

(A) Exercise.

(B) Smoking cessation.

(C) Alcohol avoidance.

(D) Weight reduction.

11. S.K.’s new onset diabetes mellitus is currently being managed only by diet, and his most recent

hemoglobin A1c was 9.2%. Which one of the following drugs is the best choice for S.K.? (A) Pioglitazone.

(B) Glipizide.

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(C) Metformin.

(D) Acarbose.

12. S.K.’s lipid profile obtained 1 week ago shows the following: total cholesterol 208 mg/dL, low -density lipoprotein 90 mg/dL, high density lipoprotein 42 mg/dL and triglycerides 310 mg/dL.S.K. refuses to take a hydroxymethyl glutaryl coenzyme A (HMG CoA) reductase inhibitorbecause he developed severe muscle pain when he took simvastatin in the past.

Based on these results, which one of the following interventions is most appropriate for S.K.?

(A) Gemfibrozil.

(B) Colesevelam.

(C) Ezetimibe.

(D) Niacin.

13. Which one of the following maintenance immunosuppression regimens would be most effective inpreventing long-term complications in a patient with significant family history of diabetes

mellitus, established hyperlipidemia, and a body mass index of 36 kg/m 2 ?

(A) Tacrolimus, mycophenolate mofetil, and prednisone.

(B) Tacrolimus, mycophenolate mofetil, and early corticosteroid withdrawal.

(C) Cyclosporine, mycophenolate mofetil, and prednisone.

(D) Cyclosporine, mycophenolate mofetil, and early corticosteroid withdrawal.

14. F.T. is a 38-year-old woman who received a transplant in 2005. She has had multiple fractures,most recently 2 months ago. Laboratory values at the time included serum creatinine 1.6 mg/dL,proteinuria 280 mg/day, calcium 11.2 mg/dL, and intact parathyroid hormone 1090 pg/mL; shetakes tacrolimus, mycophenolate mofetil, and prednisone. Today, F.T. presents to the clinic withpain and swelling in her big toe, which is assumed to be gout. Which one of the following drugswould be the best for this gout flare?

(A) Prednisone.

(B) Ibuprofen.

(C) Celecoxib.

(D) Colchicine.

15. S.W., who received a kidney transplant 22 years ago and still has adequate allograft function,was recently diagnosed with squamous cell carcinoma. His current regimen includes cyclosporine(trough 96 ng/mL) and prednisone 2.5 mg/day. Which one of the following is the mostappropriate modification to his immunosuppression regimen?

(A) Switch cyclosporine to tacrolimus.

(B) Switch cyclosporine to sirolimus.

(C) Switch cyclosporine to mycophenolate mofetil.

(D) Discontinue cyclosporine and increase prednisone dose.


M.G. is a 45-year-old recipient of a kidney transplant about 13 years ago who is takingcyclosporine (trough 249 ng/mL), azathioprine (50 mg/day), prednisone (5 mg every other day),metoprolol, diltiazem, atorvastatin, finasteride, and aspirin. He has recently been diagnosed withnew-onset diabetes mellitus and a kidney biopsy for rising creatinine concentration revealedchronic allograft nephropathy. Twenty-four-hour urine collection reveals creatinine clearance of 46 mL/minute and protein excretion of 440 mg/day.

Which one of the following changes to his immunosuppressive regimen is the best choice forM.G.?

(A) Switch cyclosporine to sirolimus.

(B) Taper prednisone and cyclosporine dose.

(C) Switch cyclosporine to mycophenolate mofetil.

(D) Switch cyclosporine to tacrolimus.

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17. M.G.’s blood pressure is 150/86 mm Hg at his next visit. Which one of the following drugs shouldbe started at this time?

(A) Furosemide.

(B) Hydrochlorothiazide.

(C) Terazosin.

(D) Losartan.

18. D.T. is a 56-year-old man who received a kidney transplant in 2004. He has a history of myocardial infarction and hypertension. He is currently taking metoprolol succinate and clonidinefor his blood pressure, and his serum creatinine is 1.4 mg/dL, total cholesterol is 179 mg/dL, andhemoglobin is 15.9 g/dL. Which one of the following drugs should be added for the managementof D.T.’s hypertension at this time?

(A) Labetalol.

(B) Minoxidil.

(C) Lisinopril.

(D) Nifedipine.

19. S.L. is a 46-year-old woman who presents for routine follow-up 7 months after her kidney

transplant. Current issues include new onset diabetes mellitus (hemoglobin A1c 6.3%),dyslipidemia (total cholesterol 187 mg/dL, low-density lipoprotein 121 mg/dL, high-densitylipoprotein 40 mg/dL, and triglycerides 256 mg/dL), and tobacco use. Patient states that “she isstarting to go through menopause” and appears nervous and upset. Which one of the followingissues is most important to address with pharmacological therapy at this time?

(A) Tobacco dependence.

(B) Perimenopausal symptoms.

(C) Dyslipidemia.

(D) Diabetes mellitus.

20. L.M. is a 29-year-old woman who received a living-donor kidney transplant in 1998 who has aserum creatinine of 1.2 mg/dL, 24-hour creatinine clearance of 58 mL/minute, and

microalbuminuria (between 100 mg/day and 225 mg/day). The patient ’s comorbidities includehypertension (treated with amlodipine and ramipril) and hyperlipidemia (treated withsimvastatin). Her current immunosuppressive regimen consists of cyclosporine (trough 145ng/mL), mycophenolate mofetil, and prednisone. L.M. tells you that she and her husband hope toconceive their second child within the next few months and asks if that is okay. Which one of thefollowing responses is most appropriate?

(A) She can safely become pregnant at this time.

(B) She cannot safely become pregnant at this time.

(C) Further testing is required before she becomes pregnant.

(D) After drug changes, she can become pregnant.


M.M. is a 28-year-old Caucasian man with type 1 diabetes mellitus who was evaluated forpossible living-related kidney transplantation from his sister. After an initial discussion about drugtherapy including calcineurin inhibitors, M.M. expressed that he wanted to avoid any drug -causingtoxicity to his transplated kidney. He then asked if there are any genetic tests that can be doneto see if he is at risk for calcineurin -induced nephrotoxicity.

Which one of the following is the most appropriate polymorphism to test to reduce M.M. ’s risk of drug toxicity?

(A) His adenosine triphosphate-binding cassette family genes ( ABCB1).

(B) His sister’s cytochrome P450 (CYP) 3A5.

(C) Tumor necrosis factorα (TNFα) and interleukin (IL)-10.

(D) His sister’s ABCB1.

22. M.M.’s sister is being evaluated as a donor in the transplantation clinic. Her blood is drawn. Whichone of the following polymorphisms is best to be obtained from the sister ’s DNA to predict M.M.’s

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risk of acute rejection?

(A) Interleukin-10.

(B) Interleukin-1.

(C) Interferon (IFN)γ.

(D) Vascular endothelial growth factor (VEGF).

23. Which one of the following immunosuppressive drugs would be most appropriate to include in aninvestigation of the effect of IL-2 receptor polymorphisms on drug response in kidneytransplantation?

(A) Thymoglobulin.

(B) Basiliximab.

(C) Cyclosporine.

(D) Sirolimus.


H.R. is a 60-year-old African-American man who is scheduled to undergo kidney transplantation.During his pretransplantation workup, he has pharmacogenomic testing.

Which one of the following CYP3A5 is most likely to be detected in H.R.?

(A) CYP3A5*1*3.

(B) CYP3A5*3*3.

(C) CYP3A5*3*5 .

(D) CYP3A5*3*6.

25. Which one of the following drug disposition pharmacogenetic markers may indicate a moredifficult post-transplantation course for H.R.?

(A) Uridine diphosphate glucuronosyltransferase (UGT) 1A9 variant frequency.

(B) ABCB1 3435 CC frequency.

(C) Multidrug resistance-associated protein (MRP)-2 variant frequency.

(D) CYP3A5*3*3.

26. Given a representative random sample of the world ’s population, which one of the followingCYP3A genes is most likely to be functionally polymorphic?

(A) CYP3A4.

(B) CYP3A7.

(C) CYP3A5.

(D) CYP3A43.

27. Which one of the following gene variants changes the amino acid sequence in ABCB1 genepolymorphism?

(A) C3435T variant at exon 26.

(B) G2677T variant at exon 21.

(C) G4030C variant at exon 28.

(D) C1236T variant at exon 12.


One of the recipients of a kidney transplant whom you are monitoring, D.R., has a decreasing

white blood cell count. Today’s result is 1800/mm3. D.R. is being treated with mycophenolatemofetil 2 g/day, and despite an extensive workup there are no other apparent reasons forleukopenia. The patient has not undergone DNA analysis of polymorphisms.

Which one of the following pharmacogenetic reasons is the most likely cause of D.R. ’sleukopenia?

(A) An MRP2 polymorphism that increases mycophenolic acid (MPA) plasma concentrations

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of MPA.

(B) An inosine monophosphate dehydrogenase (IMPDH)-2 polymorphism that decreasesIMPDH activity.

(C) A UGT1A9 polymorphism that increases plasma concentrations of MPA.

(D) An IMPDH1 polymorphism that increases IMPDH activity.

29. Which one of the following actions is best to take for D.R. at this time?

(A) Measure D.R.’s plasma MPA concentrations before taking further action.

(B) Take D.R. off of MPA.

(C) Reduce the mycophenolate mofetil dose to 1 g/day.

(D) Send off a blood IMPDH activity to the laboratory that measures this in Germany.

30. Which one of the following genotypes would help predict D.R. would attain early therapeutictacrolimus concentrations?.

(A) CYP3A5*1*1.

(B) CYP3A4*1B.

(C) CYP3A5*3*3.

(D) CYP3A5*1*3.

31. Which one of the following statements is correct regarding relationship of sirolimus concentrationand genotypes of CYP3A and ABCB1?

(A) The C3435T mutation has a significant association with sirolimus concentration and dose.

(B) The CYP3A5*1*1 showed the lowest sirolimus concentration and dose in recipients of kidney transplants.

(C) The CYP3A5 and ABCB1 genotypes do not have any significant association with sirolimusconcentration in recipients of kidney transplants.

(D) The CYP3A5 does not have any significant association with sirolimus concentration inrecipients of kidney transplants.

32. Which one of the following is associated with the highest incidence of cyclosporine -inducednephrotoxicity in recipients of kidney transplants?

(A) Donor ABCB1 3435TT genotype.

(B) Recipient ABCB1 3435 CC genotype.

(C) Donor ABCB1 3435 CC genotype.

(D) Recipient ABCB1 3435 TT genotype.

33. T.G., a 67-year-old Caucasian woman, had received a kidney transplant 10 years ago. Recently,she has developed a hip fracture and had total hip replacement surgery. The transplantationnephrologist asked you about pharmacogenetic testing regarding the risk of osteonecrosis. Whichone of the following is the best response?

(A) There are many risk factors for osteonecrosis in recipients of transplants, advise her tohave a calcineurin polymorphism test.

(B) According to the recent studies, ABCB1 2677GG mutation increases risk of osteonecrosisin recipients of kidney transplants.

(C) T.G. already has a hip fracture, so implement standard of care instead of performing agenetic test.

(D) According to the recent studies, obtain an ABCB1 3435TT genotype test in T.G..

34. One of your patients with a kidney transplant has been taken off of mycophenolate mofetil due tosevere gastrointestinal intolerance. The patient’s kidney function is stable, and the patientremains on a calcineurin antagonist and low-dose corticosteroids. You would like to startazathioprine, but the patient has not been tested for thiopurine methyltransferase deficiency.Which one of the following is the best course of action to take at this time?

(A) Send DNA for testing for CYP3A5 polymorphism.

(B) Considering that the homozygous variant is in only 0.3% of the population, start

azathioprine at the higher dose.

(C) Start azathioprine at a normal dose, and monitor white blood cell counts.

(D) Send DNA for using of IMPDH polymorphism.

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35. A 38-year African-American man with type 1 diabetes mellitus came to the transplantation clinicfor a workup for living-related kidney transplantation. During the pretransplant workup andpharmacogenetic study, he was found to have CYP3A5*1*1 and multidrug resistance gene ABCB1 exon 26 C3435C genotype. His transplantation physician asks you about its significance forinitiating his post-transplantation immunosuppression including tacrolimus, mycophenolatemofetil, and prednisone. Which one of the following is the best response?

(A) Because of his ethnicity, his pharmacogenetic results would not affect hisimmunosuppression regimen.

(B) He will need higher doses of tacrolimus and corticosteroids for maintaining thetherapeutic concentration.

(C) Because of his genotypes, he will need a higher dose of mycophenolate mofetil.

(D) Because of his genotypes, he will need a lower dose of tacrolimus.

36. A 48-year-old Japanese man with type 2 diabetes mellitus came to the transplantation clinic for aworkup for living-related kidney transplantation. During the pretransplantation workup andpharmacogenetic study, he was found to have CYP3A5 1*3 and MDR1 exon 26 T3435T genotype.His transplantation physician asks you how these genotypes affect your decision in initiating hispost-transplantation immunosuppression, including tacrolimus, mycophenolate mofetil, andprednisone. Which one of the following is the best response?

(A) Because of his ethnicity, kidney transplantation is contraindicated.

(B) His genotypes show that he will need lower doses of tacrolimus and corticosteroids formaintaining the desired therapeutic concentration.

(C) Because of his genotypes, he will need a desired higher dose of mycophenolate mofetil.

(D) Because of his genotypes, he will need a higher dose of tacrolimus.

37. A 28-year Caucasian woman with type 1 diabetes mellitus had received a six antigen -matchedliving-donor kidney transplantation from her brother 8 hours before and her initialimmunosuppression included cyclosporine 200 mg 2 times/day, azathioprine 150 mg/day orally,and prednisone 40 mg for three doses and rapidly taper. Other drugs she is taking includeinsulin, hypertension drugs, and infection prophylaxis, such as acyclovir, cotrimoxazole, andnystatin. On day 2, she developed a severe leukopenia with a white blood cell count of

1200/mm3. Which one of the following is the best management stategy for her leukopenia?

(A) Hold acyclovir, cotrimoxazole, and azathioprine.

(B) Hold azathioprine, acyclovir, and cotrimozole and test her thiopurine S -methyltransferase (TPMT) genotype before resuming her azathioprine dose.

(C) Leukopenia is common in recipients of transplants, so increase her prednisone dose.

(D) Please check white blood cell count differentials and hold azathioprine only if the

neutrophil count is less than 500/mm 3.

38. A 58-year-old Hispanic man with hypertension came to the transplantation clinic for a workup fora deceased donor kidney transplantation. During the pretransplantation workup andpharmacogenetic study, he was found to have CYP3A5 1*1. His transplantation physician asksyou about the potential implication in designing his tacrolimus dose post-transplantation. Whichone of the following is the best response?

(A) This patient will require a higher dose compared with the patient with CYP3A5*3 because

his CYP3A enzyme activity is high and it will take more time for him to achieve therapeuticconcentrations.

(B) Because he is Hispanic, his tacrolimus dose on average should be between the dose forCaucasians and the dose for African Americans.

(C) The patient will require a lower dose compared with the patient with CYP3A5*3 becausehis CYP3A enzyme activity is low and it will take more time for him to achieve therapeuticconcentrations.

(D) The patient will require a higher dose compared with the patient with CYP3A5*3 becausehis CYP3A enzyme activity is low and it will take less time for him to achieve therapeuticconcentrations.

39. A 42-year-old Caucasian man with immunoglobulin A nephropathy came to the transplantationclinic for a workup for a living-related kidney transplantation. During the pretransplantationworkup and pharmacogenetic study, he was found to have CYP3A5 1*3. His transplantation

physician asks you about its significance for initiating his cyclosporine dose. Which one of thefollowing is the best response?

(A) Because of his age, the pharmacogenetic study result would not affect hisimmunosuppression regimen.

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(B) He will need higher doses of cyclosporine and corticosteroids for maintaining thetherapeutic concentration.

(C) Because of his genotypes, he will need a higher dose of mycophenolate mofetil.

(D) Although the relationship between CYP3A5 genotype and tacrolimus dose is well defined,the relationship between CYP3A5 genotype and cyclosporine dose is not well established.

40. A 34-year-old African-American woman with systemic lupus erythematosus came to thetransplantation clinic for a rising serum creatinine concentration. She had received her living -

related donor kidney allograft 1 year ago. Her immunosuppression regimen includes tacrolimus 3mg 2 times/day, mycophenolate mofetil 1000 mg 2 times/day, and prednisone 10 mg/day. Herbaseline serum creatinine concentration had been 1.6–2 mg/dL and her serum creatinineconcentration today was 2.9 mg/dL. A kidney biopsy was done, which showed acute cellularrejection. The physician asked you whether genotyping of cytokines such as TNF α, or IL-10 wouldhelp manage the patient’s rejection. Which one of the following is the best response?

(A) Because of her ethnicity, cytokine genotyping would not affect her immunosuppressionregimen.

(B) The therapeutic application for genotype of cytokines such as TNF α or IL-10 has not yetbeen well established.

(C) Because of her ethnicity, she will need a higher dose of mycophenolate mofetil.

(D) Instead of genotyping, carefully monitor her serum cytokine concentrations to decrease

her risk of rejection.41. Questions 41–43 pertain to the following case.

S.C. is a 57-year-old African-American man with kidney failure treated with dialysis secondary todiabetes. The patient was maintained on peritoneal dialysis for 2 years before transplantationwith significant weight gain; his body mass index (BMI) at the time of transplantation was 35

kg/m2 . He underwent a deceased donor kidney transplantation last evening. The donor was a47-year-old woman who died as the result of an automobile crash. The cold ischemia time was 6hours. His intraoperative immunosuppression regimen consisted of 30 mg intravenousalemtuzumab, 500 mg intravenous methylprednisolone, and 1 g intravenous mycophenolatemofetil (MMF). On postoperative day 1, S.C.’s serum creatinine concentration decreased from 8.6mg/dL to 8.3 mg/dL. Urine output was 50 mL/hour. Before transplantation, S.C. produced about1 L/day of urine. He received a standard 7-day taper of corticosteroids and MMF 1 g orally 2times/day. On postoperative day 7, S.C.’s kidney function improved. Serum creatinine

concentration decreased to 4 mg/dL. However, 1 day later, he developed a fever of 101.2°F andurine output decreased from 200 mL/hour to 0 mL/hour.

Which one of the following risk factors affects the development of delayed allograft function(DGF) for this kidney?

(A) 47-year-old recipient.

(B) 57-year-old donor.

(C) Recipient with diabetes.

(D) 6-hour cold ischemia time.

42. Which one of the following is the best immunosuppressive strategy given S.C. ’s kidney functionon postoperative day 1?

(A) Continue the prescribed immunosuppression regimen.

(B) Thymoglobulin 1.5 mg/kg once daily for 14 days.

(C) Initiate tacrolimus 2 mg orally 2 times/day.

(D) Initiate sirolimus 8 mg and continue with 4 mg/day.

43. Which one of the following early transplant complications is most likely given the clinical eventsof postoperative day 8?

(A) Urinary tract infection.

(B) Deep wound infection.

(C) Renal artery thrombosis.

(D) Urine leak.

44. Which one of the following is the best pharmacological treatment for hypertension associatedwith diagnosed transplant renal artery stenosis?

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(A) Lisinopril.

(B) Furosemide.

(C) Extended-release diltiazem.

(D) Amlodipine.

45. W.B. is a 28-year-old Caucasian woman with kidney failure treated with dialysis secondary tolupus nephritis. She underwent a living unrelated kidney transplantation from her husband about2 months ago. After transplantation, her serum creatinine concentration decreased from 5.7mg/dL to 0.8 mg/dL. Her tacrolimus dose recently was decreased from 4 mg every 12 hours to 3mg every 12 hours, and her tacrolimus concentrations decreased from 12 ng/mL to 8 ng/mL. Shecomes to the clinic today with a serum creatinine concentration of 1.8 mg/dL and a bloodpressure of 170/95 mm Hg. W.B. states that she took her five antihypertensive drugs 5 hoursago. Her tacrolimus trough concentration today is 7.8 ng/mL. Which one of the followingsymptoms is most consistent with transplant renal artery stenosis?

(A) 3+ pitting edema bilaterally.

(B) Tacrolimus toxicity.

(C) Abrupt cessation of urine output.

(D) Refractory hypertension.


R.Q. is a 34-year-old Caucasian man with a history of failed kidney transplantation from hishuman leukocyte antigen (HLA) identical brother 15 years ago. To his knowledge, he did notreceive any induction therapy. His kidney function has progressively declined and his initialtransplantation evaluation for a second transplant was started. R.Q. has no other significant pastsurgical or medical history. He comes to the clinic today for preadmission testing for a pre -emptive living unrelated transplant from a friend. The transplantation team also plans to discusswhat type of induction therapy to administer to R.Q. for his second transplantation. They decideto use rabbit-antithymocyte globulin because R.Q. is receiving a second transplantation and hasan elevated percent panel reactive antibody (PRA).

Which one of the following places R.Q. at highest risk for a wound -healing complication post-

transplantation? (A) Body mass index is greater than 30 kg/m 2 .

(B) Failed his glucose tolerance test.

(C) Panel reactive antibody screening is greater than 50%.

(D) Chronic corticosteroid use.

47. Five days after receiving rabbit-antithymocyte globulin, R.Q. returned to the clinic for a routinefollow-up visit. He is asking when he can return to his veterinary clinic and begin seeing “patients.” At that time, it was noted that R.Q. had an abnormal gait. His wife indicated that thisstarted in the past 24 hours; on further examination, it was noted that his knees were swollenand he had some pain in his left hip. R.Q. also had a low -grade fever and slightly elevated serumcreatinine concentration 1.2 mg/dL, up from 1 mg/dL.

Which one of the following diagnoses is the most likely based on R.Q. ’s symptoms?

(A) Gouty flare.

(B) Serum sickness.

(C) Osteomyelitis of the hip and knees.

(D) Acute cellular rejection.

48. R.Q. did well after his transplantation. His serum creatinine concentration decreased to 0.9mg/dL. His maintenance immunosuppression consisted of tacrolimus 4 mg 2 times/day, MMF 1.5g 2 times/day, and prednisone tapered to 10 mg by 3 months. Six months after transplantation,R.Q. returns to the clinic complaining of a fine tremor that he notices when he reads thenewspaper. His tacrolimus level is 16 ng/mL and he is complaining of severe diarrhea (more thaneight stools per day).

Which one of the following is the best course of action to resolve R.Q. ’s hand tremor?

(A) Switch tacrolimus to cyclosporine.

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(B) Discontinue prednisone.

(C) Decrease the tacrolimus dose.

(D) Decrease the MMF dose.


A.J. is 39-year-old Caucasian woman with kidney failure treated with dialysis secondary to

polycystic kidney disease. Her PRA is 0%. She has no children. She underwent a deceased donortransplant about 2 weeks ago. The allograft was procured from a 56 -year-old Caucasian man whodied as a result of a cerebral vascular accident. The cold ischemia time was 36 hours. A.J.experienced significant DGF, requiring renal replacement therapy for 10 days post -transplantation. Immunosuppression included rabbit antithymocyte globulin, 7 days of corticosteroids, tacrolimus, and MMF. On postoperative day 8, she received 1 unit of blood and akidney biopsy was performed which revealed antibody-mediated rejection.

Which one of the following would most contribute to A.J. developing antibody -mediated rejection?

(A) Receiving 1 unit of blood on postoperative day 8.

(B) Having never been pregnant.

(C) Donor died of a cerebral vascular accident.

(D) Cold ischemia time of 36 hours.

50. A.J. received 1 week of therapy with plasmapheresis and 2 g/kg intravenous immune globulin.However, her serum creatinine concentration remained at 6 mg/dL and her donor-specificantibody titer increased.

Given A.J.’s clinical course, which one of the following is the best treatment option if her repeatkidney biopsy reveals continued antibody-mediated rejection?

(A) Continue with plasmapheresis and immune globulin.

(B) Administer methylprednisolone 500 mg/day for 3 days.

(C) Administer a single dose of rituximab 375 mg/m 2 .

(D) Administer a repeat course of rabbit antithymocyte globulin.

51. A.C., a 32-year-old African-American man, was admitted to the emergency department 10 hoursago after his fiancée insisted that he be seen for several red raised lesions on his skin and someacute mental status changes. His fiancée indicated that since this morning A.C. was havingdifficulty “finding his words.” A.C. had a medical history significant for prostate cancer, which wasdiagnosed 1 year ago. He currently is a grade school physical education teacher and PeeWeeleague soccer coach. Recently, several of his soccer team members were out with the chickenpox. In the emergency department, A.C. became progressively lethargic; while the nurse wasgetting the attending emergency department physician, A.C. had a seizure while trying to leavethe room. He fell and hit his head on the side of the bed. A.C. was intubated and transferred toradiology, where a computed tomography scan revealed a diffuse subarachnoid hemorrhage. A.C.was transferred to the intensive care unit. Over the next 2 days, he did not respond tocommands. A follow-up magnetic resonance imaging study of the head was obtained and thehemorrhage had extended to the brain stem. A.C. was maintained on dopamine 10

mcg/kg/minute and received combined hormonal therapy (triiodothyronine, vasopressin,methylprednisolone) to maintain a mean arterial pressure greater than 70 mm Hg. He also wasstarted on piperacillin-tazobactam for a left upper lobe infiltrate and probable aspirationpneumonia. Blood cultures were negative. Hepatitis B and C and Human Immunodeficiency Virusserologies were negative. During morning rounds, the intern asks you if A.C. should beconsidered for organ donation. Which one of the following would preclude A.C. ’s wish to donatehis organs?

(A) Upper lobe infiltrate suggestive of pneumonia.

(B) Prostate cancer diagnosed 1 year ago.

(C) Subarachnoid hemorrhage.

(D) Chicken pox infection.


R.L. is a 23-year-old Caucasian woman with kidney failure treated with dialysis secondary toreflux nephropathy. She underwent a living donor transplant 4 months ago without incident.





Today, she comes to the clinic with an increased serum creatinine concentration, 1.4 mg/dL froma nadir of 1.0 mg/dL. Her electrolytes are unremarkable. However, white blood cell count is 8

cells/mm3, hemoglobin is 7.8 mg/dL, and platelet count is 260 cells/mm 3. She reports low-gradefevers over the past week and notes monoarticular wrist and knee swelling for which she receiveda short course of corticosteroids. She also was treated for acute cellular rejection 2 monthsbefore this admission which was treated with a corticosteroid pulse. Otherwise, she has beenmaintained on tacrolimus 1 mg 2 times/day and MMF 1 g 2 times/day. Last night, the fellowdecided to give a 500 mg bolus of methylprednisolone because R.L. has had a recent previous

rejection and increased serum creatinine concentration. The biopsy results were obtained thismorning and reveal diffuse microangiopathic hemolysis. Laboratory test results today reveal a

serum creatinine concentration 2.3 mg/dL, white blood cell count 17 cells/mm 3, hemoglobin 7

mg/dL, platelet count 150 cells/mm3, total bilirubin 1.4 mg/dL, aspartate transaminase 47 IU/L,alanine transaminase 70 IU/L, and alkaline phosphatase 180 IU/L. The tacrolimus concentrationwas 17 ng/mL.

Which one of the following laboratory test results is most consistent with thromboticmicroangiopathy/hemolytic uremic syndrome?

(A) Total bilirubin of 1.4 mg/dL.

(B) Tacrolimus level of 17 ng/mL.

(C) White blood cell count of 17 cells/mm3.

(D) Hemoglobin of 7 g/dL.

The same day that the biopsy results are obtained, you walk into the research office and thetransplantation physicians are discussing what therapy they should implement for R.L. Theywant to shorten the duration of the hemolysis and stop formation of new lesions in thekidney.

53. Which one of the following options is the best choice for R.L. at this time?

(A) Discontinuation of the calcineurin inhibitor (CNI).

(B) Administration of whole blood.

(C) Plasmapheresis.

(D) Corticosteroids.

54. Seven days later, R.L.’s kidney function has improved and her serum creatinine concentration isback at baseline. The attending physician asks you what immunosuppression regimen should beselected for R.L. upon discharge.

In addition to MMF, which one of the following immunosuppression regimens is the best choicegiven R.L.’s current and previous history?

(A) Sirolimus.

(B) Cyclosporine.

(C) Corticosteroids.

(D) Tacrolimus.

55. Question 55 and 56 pertain to the following case.

B.J. is a 54-year-old Caucasian man who underwent kidney transplantation 7 months agosecondary to hypertension-induced nephrosclerosis. He was converted to sirolimus last month todecrease CNI exposure. He comes to the clinic today with progressive dry cough and audiblerales bilaterally upon lung auscultation. His chest radiograph reveals patchy infiltrates. He ishemodynamically stable, but is febrile to 100.2°F. His current drugs include sirolimus 4 mg/day,MMF 1 g 2 times/day, prednisone 10 mg/day, single-strength sulfamethoxazole-trimethoprimonce daily, metoprolol 50 mg 2 times/day, and amiodarone 200 mg/day (started onpostoperative day 3).

Which one of the following should be the most likely on the differential diagnosis with this type of patient presentation?

(A) Pneumocystis jiroveci

(B) βBlocker-induced bronchoconstriction.

(C) Amiodarone-induced pneumonitis.





(D) Cytomegalovirus pneumonia.

56. All viral, fungal, and bacterial cultures came back negative and B.J. ’s respiratory functioncontinued to decline despite appropriate antimicrobial coverage. Sirolimus -induced pneumonitiswas deemed the most likely etiology of B.J.’s condition. Sirolimus was discontinued this morningand B.J. did not receive his dose. The nurse asks you to talk to B.J. about why the sirolimus isbeing discontinued. You talk to B.J. about sirolimus-induced pneumonitis and he wants to knowwhen his cough will resolve.

Which one of the following responses to B.J.’s question is best?

(A) Later today.

(B) Tomorrow morning.

(C) Two weeks from today.

(D) Six weeks from today.


H.G. is an 18-year-old African-American man with kidney failure treated with dialysis secondary

to immunoglobulin A nephropathy. He has a BMI of 24 kg/m 2 . A deceased donor organ hasbecome available for him and he is scheduled to undergo kidney transplantation in 2 hours. The

allograft cold ischemia time is expected to be more than 20 hours. He has a medical historysignificant only for hypertension, which has been well controlled with amlodipine 10 mg/day andenalapril 5 mg 2 times/day. His was scheduled for hemodialysis today. He will receive rabbit -antithymocyte globulin induction, methylprednisolone 500 mg, followed by a 7 -day corticosteroidtaper, and MMF as his peritransplantation immunosuppression.

Which one of the following places H.G. at highest risk post -transplantation hyperglycemia?

(A) Corticosteroids.

(B) Rabbit-antithymocyte globulin.

(C) His age.

(D) H.G.’s body mass index.

58. Three years after transplantation, H.G. goes to the emergency department with his new wife whostates that he has trouble “finding his words,” which has become progressively worse over thepast few weeks. He currently is taking tacrolimus 3 mg 2 times/day and MMF 1 g 2 times/day. Acomputed tomography scan of the head revealed bilateral contrast enhancing lesions. Biopsy of these lesions revealed post-transplantation lymphoproliferative disorder (PTLD).

Which one of the following factors in H.G.’s history placed him at highest risk for PTLD?

(A) Induction with rabbit-antithymocyte globulin.

(B) Maintenance therapy with MMF.

(C) Maintenance therapy with tacrolimus.

(D) High-dose corticosteroids peri-transplantation.

59. Which one of the following is the best initial therapy for H.G.? (A) Administer rituximab.

(B) Initiate intravenous immune globulin.

(C) Decrease current immunosuppression.

(D) Administer alemtuzumab.

60. J.K. is a 42-year-old African-American woman with kidney failure treated with dialysis secondaryto diabetic nephropathy. She received a living donor transplant from her sister about 2 weeksago. She received thymoglobulin induction, and currently is taking tacrolimus 4 mg 2 times/day,MMF 1.5 g 2 times/day, and prednisone 15 mg/day. She comes to the clinic today complaining of diarrhea (greater than six stools per day) and shaking tremor. Which one of the followinglaboratory test results is most consistent with J.K.’s clinical picture?

(A) Subtherapeutic tacrolimus concentration and serum creatinine concentration less thanbaseline.

(B) Supratherapeutic tacrolimus concentration and elevated serum creatinine concentration.



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