certified Clinical Transplant Nurse Examination (CCTN®) , again
covering Pre-Transplant, Peritransplant, and Post-Transplant
Patient Management with a mixed difficulty level (advanced, hard,
scenario-based) for experienced professionals.
Section 1: Pre-Transplant Evaluation & Management (Questions 1–35)
1. A 62-year-old with hepatitis C cirrhosis (now cured) and HCC within Milan criteria is listed for liver transplant.
Which finding would most likely lead to delisting?
A) New solitary 2.5 cm lesion with AFP 200 ng/mL
B) Portal vein thrombosis with cavernous transformation
C) Severe pulmonary hypertension (mPAP 48 mmHg) responsive to vasodilators
D) Refractory hepatic hydrothorax requiring pleurodesis
Correct Answer: B
Rationale: Portal vein thrombosis with cavernous transformation is not a contraindication, but complete
portomesenteric thrombosis may preclude transplant; however, HCC growth beyond Milan criteria (new
lesion >3 cm or >3 lesions) would delist. Option A describes possible progression beyond Milan.
2. A 45-year-old with Type 1 diabetes and eGFR 55 mL/min is considering a preemptive pancreas transplant alone
(PTA). What is the major contraindication?
A) BMI 28
B) History of diabetic retinopathy
C) eGFR <60 mL/min
D) Age >40
Correct Answer: C
*Rationale: PTA requires eGFR >60 mL/min because calcineurin inhibitors will worsen renal function. Stage 3 CKD is a
relative contraindication.*
3. Which pre-transplant cardiac test is recommended for a 50-year-old asymptomatic kidney candidate with
hypertension but no diabetes?
A) No routine cardiac testing
B) Dobutamine stress echocardiography
C) Coronary CT angiography
D) Resting ECG only
Correct Answer: A
Rationale: According to KDIGO and AHA, asymptomatic patients without diabetes or known CAD do not
require routine stress testing.
4. A highly sensitized patient (CPRA 99.5%) with a living donor who is ABO-compatible but crossmatch-positive.
Which strategy is most appropriate?
A) Proceed with transplant without desensitization
B) Desensitization with IVIG + plasmapheresis
C) List for deceased donor only
,D) Perform donor-specific transfusion
Correct Answer: B
Rationale: Desensitization can convert a positive crossmatch to negative in many cases, enabling living
donor transplant.
5. A 28-year-old with primary hyperoxaluria type 1 is being evaluated for transplant. Which organ(s) should be
considered?
A) Isolated kidney transplant
B) Combined liver-kidney transplant
C) Isolated liver transplant
D) Pancreas-kidney transplant
Correct Answer: B
*Rationale: Primary hyperoxaluria type 1 is a liver enzyme defect; combined liver-kidney transplant corrects the
metabolic defect and replaces failed kidneys.*
6. What is the recommended minimal period of smoking cessation before listing for lung transplant?
A) 3 months
B) 6 months
C) 12 months
D) No required period
Correct Answer: B
Rationale: Most programs require 6 months of documented smoking cessation with negative cotinine
testing.
7. Which finding on pre-transplant psychosocial evaluation is most predictive of post-transplant non-adherence?
A) History of anxiety treated with SSRI
B) Prior transplant with excellent adherence
C) History of multiple substance relapses despite rehabilitation
D) Living alone
Correct Answer: C
Rationale: Repeated relapses indicate high risk of non-adherence with immunosuppression.
8. A liver candidate has a MELD-Na score of 28 but also has hepatopulmonary syndrome (HPS) with PaO2 52 mmHg
on room air. What is the priority?
A) Wait for MELD score to increase naturally
B) Apply for MELD exception points
C) Perform liver biopsy
D) List for combined liver-lung transplant
Correct Answer: B
*Rationale: HPS with PaO2 <60 mmHg qualifies for MELD exception points (usually 22-40), increasing priority.*
9. A 55-year-old with polycystic kidney disease (PKD) is being evaluated. Which additional study is required before
kidney transplant?
A) Renal artery duplex
B) CT abdomen to assess for concurrent liver cysts
C) Screening colonoscopy
, D) Echocardiogram for valvular disease
Correct Answer: D
Rationale: PKD is associated with mitral valve prolapse and aortic root dilation; echocardiogram is
indicated.
10. A patient with a prior kidney transplant lost to chronic rejection is now being re-listed. Current CPRA is 85%.
Which is true?
A) Prior transplant does not affect CPRA
B) Repeat transplant has similar outcomes to first transplant
C) Sensitization from prior transplant increases risk of rejection
D) Desensitization is never effective
Correct Answer: C
Rationale: Prior transplant increases sensitization; higher CPRA and risk of AMR.
11. Which live vaccine may be given to a patient on the waiting list for lung transplant?
A) MMR if seronegative
B) Varicella if no history of chickenpox
C) Yellow fever if traveling to endemic area
D) None – live vaccines are contraindicated pre-transplant
Correct Answer: D
Rationale: Live vaccines are generally contraindicated in transplant candidates because post-transplant
immunosuppression could cause disseminated infection.
12. A 34-year-old with alcoholic cirrhosis has completed 6 months of abstinence. What additional pre-transplant
requirement is standard?
A) Negative liver biopsy for steatohepatitis
B) Random urine drug screen
C) Contract for post-transplant alcohol abstinence with random testing
D) MELD score <20
Correct Answer: C
Rationale: Written abstinence contract with random alcohol/drug screening is standard.
13. Which hemoglobin A1c range is acceptable for listing a diabetic patient for kidney transplant?
A) <6.0%
B) 6.0-7.0%
C) 7.0-8.5%
D) >8.5%
Correct Answer: B
*Rationale: Target HbA1c 6-7% pre-transplant; >8.5% increases perioperative risk.*
14. A 60-year-old with non-alcoholic steatohepatitis (NASH) cirrhosis is listed for liver transplant. What comorbidity
most increases post-transplant cardiovascular risk?
A) Osteoarthritis
B) Coronary artery disease with prior stents
C) Gout
D) Atrial fibrillation well-controlled
covering Pre-Transplant, Peritransplant, and Post-Transplant
Patient Management with a mixed difficulty level (advanced, hard,
scenario-based) for experienced professionals.
Section 1: Pre-Transplant Evaluation & Management (Questions 1–35)
1. A 62-year-old with hepatitis C cirrhosis (now cured) and HCC within Milan criteria is listed for liver transplant.
Which finding would most likely lead to delisting?
A) New solitary 2.5 cm lesion with AFP 200 ng/mL
B) Portal vein thrombosis with cavernous transformation
C) Severe pulmonary hypertension (mPAP 48 mmHg) responsive to vasodilators
D) Refractory hepatic hydrothorax requiring pleurodesis
Correct Answer: B
Rationale: Portal vein thrombosis with cavernous transformation is not a contraindication, but complete
portomesenteric thrombosis may preclude transplant; however, HCC growth beyond Milan criteria (new
lesion >3 cm or >3 lesions) would delist. Option A describes possible progression beyond Milan.
2. A 45-year-old with Type 1 diabetes and eGFR 55 mL/min is considering a preemptive pancreas transplant alone
(PTA). What is the major contraindication?
A) BMI 28
B) History of diabetic retinopathy
C) eGFR <60 mL/min
D) Age >40
Correct Answer: C
*Rationale: PTA requires eGFR >60 mL/min because calcineurin inhibitors will worsen renal function. Stage 3 CKD is a
relative contraindication.*
3. Which pre-transplant cardiac test is recommended for a 50-year-old asymptomatic kidney candidate with
hypertension but no diabetes?
A) No routine cardiac testing
B) Dobutamine stress echocardiography
C) Coronary CT angiography
D) Resting ECG only
Correct Answer: A
Rationale: According to KDIGO and AHA, asymptomatic patients without diabetes or known CAD do not
require routine stress testing.
4. A highly sensitized patient (CPRA 99.5%) with a living donor who is ABO-compatible but crossmatch-positive.
Which strategy is most appropriate?
A) Proceed with transplant without desensitization
B) Desensitization with IVIG + plasmapheresis
C) List for deceased donor only
,D) Perform donor-specific transfusion
Correct Answer: B
Rationale: Desensitization can convert a positive crossmatch to negative in many cases, enabling living
donor transplant.
5. A 28-year-old with primary hyperoxaluria type 1 is being evaluated for transplant. Which organ(s) should be
considered?
A) Isolated kidney transplant
B) Combined liver-kidney transplant
C) Isolated liver transplant
D) Pancreas-kidney transplant
Correct Answer: B
*Rationale: Primary hyperoxaluria type 1 is a liver enzyme defect; combined liver-kidney transplant corrects the
metabolic defect and replaces failed kidneys.*
6. What is the recommended minimal period of smoking cessation before listing for lung transplant?
A) 3 months
B) 6 months
C) 12 months
D) No required period
Correct Answer: B
Rationale: Most programs require 6 months of documented smoking cessation with negative cotinine
testing.
7. Which finding on pre-transplant psychosocial evaluation is most predictive of post-transplant non-adherence?
A) History of anxiety treated with SSRI
B) Prior transplant with excellent adherence
C) History of multiple substance relapses despite rehabilitation
D) Living alone
Correct Answer: C
Rationale: Repeated relapses indicate high risk of non-adherence with immunosuppression.
8. A liver candidate has a MELD-Na score of 28 but also has hepatopulmonary syndrome (HPS) with PaO2 52 mmHg
on room air. What is the priority?
A) Wait for MELD score to increase naturally
B) Apply for MELD exception points
C) Perform liver biopsy
D) List for combined liver-lung transplant
Correct Answer: B
*Rationale: HPS with PaO2 <60 mmHg qualifies for MELD exception points (usually 22-40), increasing priority.*
9. A 55-year-old with polycystic kidney disease (PKD) is being evaluated. Which additional study is required before
kidney transplant?
A) Renal artery duplex
B) CT abdomen to assess for concurrent liver cysts
C) Screening colonoscopy
, D) Echocardiogram for valvular disease
Correct Answer: D
Rationale: PKD is associated with mitral valve prolapse and aortic root dilation; echocardiogram is
indicated.
10. A patient with a prior kidney transplant lost to chronic rejection is now being re-listed. Current CPRA is 85%.
Which is true?
A) Prior transplant does not affect CPRA
B) Repeat transplant has similar outcomes to first transplant
C) Sensitization from prior transplant increases risk of rejection
D) Desensitization is never effective
Correct Answer: C
Rationale: Prior transplant increases sensitization; higher CPRA and risk of AMR.
11. Which live vaccine may be given to a patient on the waiting list for lung transplant?
A) MMR if seronegative
B) Varicella if no history of chickenpox
C) Yellow fever if traveling to endemic area
D) None – live vaccines are contraindicated pre-transplant
Correct Answer: D
Rationale: Live vaccines are generally contraindicated in transplant candidates because post-transplant
immunosuppression could cause disseminated infection.
12. A 34-year-old with alcoholic cirrhosis has completed 6 months of abstinence. What additional pre-transplant
requirement is standard?
A) Negative liver biopsy for steatohepatitis
B) Random urine drug screen
C) Contract for post-transplant alcohol abstinence with random testing
D) MELD score <20
Correct Answer: C
Rationale: Written abstinence contract with random alcohol/drug screening is standard.
13. Which hemoglobin A1c range is acceptable for listing a diabetic patient for kidney transplant?
A) <6.0%
B) 6.0-7.0%
C) 7.0-8.5%
D) >8.5%
Correct Answer: B
*Rationale: Target HbA1c 6-7% pre-transplant; >8.5% increases perioperative risk.*
14. A 60-year-old with non-alcoholic steatohepatitis (NASH) cirrhosis is listed for liver transplant. What comorbidity
most increases post-transplant cardiovascular risk?
A) Osteoarthritis
B) Coronary artery disease with prior stents
C) Gout
D) Atrial fibrillation well-controlled
