Free nephrology board questions: Transplant

A 52-year-old woman with ESRD from ADPKD, hypertension, and gout is admitted with fatigue, headache, fever, and chills 10 months after kidney transplantation. She received basiliximab induction; donor and recipient were both CMV seronegative. Maintenance was tacrolimus, mycophenolate, and prednisone until mycophenolate-induced colitis 6 months post-transplant prompted replacement of mycophenolate with azathioprine. Other medications are amlodipine, omeprazole, allopurinol, and trimethoprim-sulfamethoxazole. Temperature is 37.5°C. Examination is otherwise unremarkable. WBC count 900/µL, absolute neutrophil count 200/µL, absolute lymphocyte count 400/µL, hemoglobin 9.8 g/dL, platelets 115,000/µL; creatinine 0.8 mg/dL (baseline). What is the most likely cause of her pancytopenia?

A 64-year-old man with a history of ESRD due to ADPKD status post kidney transplant 1 year ago presents for routine follow-up. His immediate post-transplant course was uncomplicated, and he was discharged after 5 days. Three weeks after discharge, he was admitted with community-acquired pneumonia, and an induced sputum culture was positive for Streptococcus pneumoniae. He had an episode of mild acute rejection 2 months after transplant that was managed successfully with high-dose corticosteroids. He has also had several instances of supratherapeutic tacrolimus trough levels and chronic diarrhea, which required decreased dosing of tacrolimus and mycophenolate, respectively. Current medications include tacrolimus, mycophenolate, and prednisone. Of note, he has a history of cannabis use, which he discontinued immediately prior to transplant (confirmed by blood testing). At this visit, he admits that 2 weeks after transplant, he resumed smoking marijuana and taking oral cannabidiol (CBD) 1–2 times per week. His peak eGFR following transplantation was 79 mL/min/1.73 m², and his current eGFR is 62 mL/min/1.73 m². Which of the following events is MOST LIKELY attributable to this patient's use of cannabis products?

A 70-year-old man on in-center hemodialysis for 1 year requests kidney transplant evaluation. History includes ANCA vasculitis unsuccessfully treated with cyclophosphamide and Gleason 7 prostate cancer treated with radiation 8 years ago, in remission. Screening colonoscopy 4 years ago was normal. He has no extrarenal vasculitis symptoms. He reports exhaustion after dialysis and a 7-kg unintentional weight loss over the past year, and he leaves home only for dialysis. Grip strength is symmetric at 3/5. PSA is <0.1 ng/mL and ESR 4 mm/h. What is the most appropriate next step in his pretransplant evaluation?

A 32-year-old woman is evaluated for potential kidney donation to her sister. She does not have any chronic medical conditions; her only medication is an over-the-counter multivitamin. Her physical examination is normal. Her BP is 120/78 mm Hg and heart rate 72/min, and she weighs 58 kg. Laboratory data include the following: sodium 141 mEq/L (reference 136–145); potassium 4.7 mEq/L (3.5–5.0); chloride 106 mEq/L (98–106); total CO₂ 23 mEq/L (23–28); BUN 10 mg/dL (8–20); creatinine 0.7 mg/dL (0.5–1.1). Which of the following is the BEST initial method for estimating her GFR?

A 48-year-old woman with a history of ESRD status post kidney transplant presents to the emergency department with 2 weeks of intermittent fevers, diarrhea, fatigue, and body aches. She is currently 8 months status post deceased donor kidney transplantation. The kidney allograft functioned immediately. She received anti-thymocyte globulin for induction. Because of positive donor hepatitis C status, the patient was prescribed 12 weeks of glecaprevir/pibrentasvir after transplant and achieved sustained virologic response. Valganciclovir and trimethoprim-sulfamethoxazole were prescribed for 6 months after transplant. Her current immunosuppressive regimen consists of tacrolimus, mycophenolate, and prednisone. Her course has been uncomplicated until the last few weeks, at which time she developed persistent fevers and diarrhea (3-6 loose stools per day). On examination, BP is 108/68 mm Hg, heart rate is 96/min, and temperature is 37.8°C. She is ill-appearing but in no distress. Her allograft is nontender, and the rest of her examination is unremarkable. Pretransplant serologic data (donor; recipient): CMV IgG +; –. EBV IgG +; +. Hepatitis B virus (HBV) surface antigen (HBsAg) –; –. HBV surface antibody (HBsAb) –; +. HBV core antibody (HBcAb) –; –. Hepatitis C virus (HCV) core antibody +; –. HCV nucleic acid test (NAT) +; –. Current laboratory data: WBC count 1.0/µL (reference 4000–11,000); hemoglobin 9.8 g/dL (12–16); serum potassium 3.3 mEq/L (3.5–5.0); total CO₂ 17 mEq/L (23–28); BUN 24 mg/dL (8–20); creatinine 1.1 mg/dL (baseline, 1.0) (0.5–1.1); alanine aminotransferase 76 U/L (10–40); aspartate aminotransferase 82 U/L (10–40); total bilirubin 1.1 mg/dL (0.3–1.0); alkaline phosphatase 128 U/L (30–120). Urinalysis reveals no protein, RBCs, or WBCs. Which ONE of the following is the MOST likely cause of this patient’s symptoms and laboratory abnormalities?

A 32-year-old man with ESRD due to FSGS status post living kidney transplant from his mother 2 years ago is seen for routine follow-up. He has well-controlled hypertension, and his post-transplant course has been uneventful. His immunosuppressive regimen consists of tacrolimus and mycophenolate mofetil. Creatinine has been at his baseline level of 0.9 mg/dL (reference range, 0.7–1.3), and tacrolimus trough is usually 5–7 ng/mL (reference range, 5–10). He is recently married and is planning to have children within the year. He is concerned about infertility with his history of kidney disease and immunosuppression. Which one of the following is the MOST APPROPRIATE next step in management?

A 60-year-old-man with ESRD due to ADPKD, status post deceased donor kidney transplant 1 year ago, presents to establish care with a nephrologist after a recent move out of state. He has not been seen by a nephrologist for 5 months. He has occasional mild headaches, but feels well overall. The headaches are bilateral and not associated with vision changes. He denies recent infections, night sweats, or pruritis. He has no daytime sleepiness. He has a 10-pack-year smoking history, but a CT scan of his chest done as part of his original transplant evaluation was without evidence of lung disease or nodules. His immunosuppressive regimen is tacrolimus, mycophenolate mofetil, and prednisone. His RBC indices were found to be elevated at his most recent transplant nephrology appointments, 5 and 6 months ago. On examination, BP is 124/76 mm Hg, heart rate is 60/min, and oxygen saturation is 99% while breathing room air. He has a normal cardiopulmonary examination. He does not have edema. Laboratory data: WBC count 3400/µL (reference 4000–11,000); hemoglobin 18.1 g/dL (pre-transplant, 11.8) (14–18); platelet count 170,000/µL (150,000–450,000); tacrolimus whole blood trough 7.7 ng/mL (5–10, >3 months after transplant). Evaluation for the V617F or other mutations in the JAK2 gene for the diagnosis of polycythemia vera is negative. Which ONE of the following is the next best step in diagnosis or management?

A 32-year-old woman presents for preconception counseling. She has ESRD due to immunoglobulin A (IgA) nephropathy. She received a kidney transplant from her husband 3 years ago. She had an episode of acute rejection 18 months ago that was successfully treated with glucocorticoids, and kidney function has subsequently been stable. Her current immunosuppressive medications are mycophenolate, tacrolimus, and prednisone. She feels well and reports no symptoms. Vital signs include a BP of 114/68 mm Hg and pulse 76/min. Physical examination is normal. Laboratory data are significant for a creatinine of 1.2 mg/dL (reference range, 0.5‒1.1). Which one of the following is the MOST APPROPRIATE recommendation regarding pregnancy planning?

A 50-year-old woman presents for follow-up in the kidney transplant evaluation clinic. She has a history of CKD stage 4 secondary to IgA nephropathy. Kidney function has slowly worsened over the last 5 years. Her current medications include lisinopril and amlodipine. BP is 125/75 mm Hg. Physical examination is unremarkable. Laboratory studies show a serum creatinine of 2.2 mg/dL (reference range, 0.5–1.1) with eGFR 25 mL/min/1.73 m² (reference range, ≥60). She previously completed her evaluation and has no contraindications to kidney transplantation. Her husband was found to be a suitable donor. The patient asks when kidney transplantation should be performed. Which ONE of the following is the OPTIMAL time for this patient to undergo kidney transplantation?

A 71-year-old man with a history of ESRD secondary to diabetes and hypertension presents for follow-up 6 months after a deceased donor kidney transplant. He received immunosuppression induction with thymoglobulin and had immediate graft function, with a nadir serum creatinine level of 1.1 mg/dL and nadir urine protein-to-creatinine ratio of 0.1 mg/mg (reference range, <0.2). Medications include tacrolimus 3 mg twice daily, mycophenolate mofetil 1 g twice daily, prednisone 5 mg daily, amlodipine 10 mg daily, and carvedilol 12.5 mg twice daily. The patient is adherent to medications and a 2 g/day sodium diet but reports his home BP has averaged 160/94 mm Hg for the last several weeks. On physical examination, BP is 164/96 mm Hg, which is confirmed with a repeat measurement after several minutes of resting in a quiet place. Cardiac and respiratory examinations are unremarkable. He has a well-healed surgical incision and a nontender allograft in the right lower quadrant. He has 1–2+ edema of his lower extremities bilaterally. Laboratory data: sodium 139 mEq/L (reference 136–145); potassium 3.0 mEq/L (3.5–5.0); chloride 103 mEq/L (98–106); total CO₂ 32 mEq/L (23–28); BUN 18 mg/dL (8–20); creatinine 1.4 mg/dL (0.7–1.3); tacrolimus 7 ng/mL (5–15, >3 months after transplantation). Urinalysis is negative for protein, WBCs, and RBCs. In addition to optimization of his BP regimen, which ONE of the following is the MOST appropriate next step in diagnosis or management?