Diabetes and Transplantation Practice Exam: Diabetes Chapter 20

For people with diabetes and end-stage renal disease (ESRD), transplantation offers the potential for significantly improved survival and quality of life compared to dialysis. However, the procedure introduces new challenges, including the management of post-transplant diabetes mellitus (PTDM) and the complex side effects of immunosuppressive therapy.

This practice exam tests your understanding of the indications for various transplant modalities (kidney, pancreas, islet) and the evidence-based strategies for managing glycemic control in the transplant recipient.

Key Concepts Covered in This Exam:

Renal Replacement: Understanding the evidence that kidney transplantation improves long-term outcomes compared to dialysis for individuals with diabetes and ESRD.
Transplant Types: Differentiating between Simultaneous Pancreas-Kidney (SPK) transplantation, which can prolong insulin independence, and islet allotransplantation, which focuses on preventing severe hypoglycemia.
Islet Autotransplantation: Recognizing the role of this procedure in preventing labile diabetes for patients undergoing total pancreatectomy for benign disease.
Post-Transplant Diabetes (PTDM): Identifying PTDM as a common complication after solid organ transplantation that increases the risk of graft loss, cardiovascular disease, and mortality.
Management Considerations: Balancing glycemic targets with the metabolic impact of antirejection medications.

1. What is the most common reason for long-term pancreas transplant loss?

Chronic graft failure

Acute rejection

Surgical complications

2. What is a potential complication specific to islet transplantation procedures?

Graft pancreatitis

Peripancreatic abscess

Duodenal stump leakage

Branch portal vein thrombosis

3. PTDM is associated with which of the following outcomes?

Improved graft survival

No impact on long-term outcomes

Reduced patient and graft survival, increased CVD, infection, and complications

Reduced cardiovascular risk

4. At what time point post-transplant can A1C ≥6.5% be used to diagnose PTDM in stable recipients?

Immediately post-transplant

After 1 month

After 3 months

After 6 months

5. A patient with type 1 diabetes underwent islet transplantation 3 years ago. She is no longer insulin-independent but maintains C-peptide secretion. What benefits can she expect from this residual graft function?

No benefit since she requires insulin

Continued protection from severe hypoglycemia and improved glycemic control

Discontinuation of immunosuppression

Complete reversal of retinopathy

6. What is the median pancreas graft survival after transplantation?

9 years

5 years

7 years

12 years

7. What is a characteristic metabolic outcome after successful pancreas transplantation?

Normal glucose tolerance with hyperinsulinemia

Persistent hyperglycemia with normal insulin levels

Hypoglycemia with absent C-peptide

Normal glucose tolerance with hypoinsulinemia

8. A patient asks about the risks of pancreas transplantation surgery. Which complications are specifically associated with pancreas transplantation surgery?

Hepatic fibrosis and biliary complications

Pulmonary embolism and cardiac arrhythmias

Portal vein thrombosis and intraperitoneal hemorrhage

Graft thrombosis, pancreatitis, and duodenal stump leakage

9. What is the 1-year graft survival rate for simultaneous pancreas-kidney (SPK) transplantation?

75.5%

96.2%

85.7%

91.3%

10. According to guidelines, when should A1C be measured to screen for PTDM after solid organ transplantation?

At 3, 12 months, and then annually

At 6 and 12 months only

At 1, 6, and 12 months, then annually

Only if symptoms develop

11. A 40-year-old woman with type 1 diabetes and ESRD is being counseled about transplant options. She wants to understand the comparative benefits of SPK versus kidney transplant alone. What is the primary advantage of SPK transplantation over kidney transplant alone in type 1 diabetes patients with ESRD?

Lower immunosuppression requirements

Shorter surgical time

No need for post-operative monitoring

Improved long-term patient and kidney graft survival

12. What is a major advantage of islet autotransplantation compared to islet allotransplantation?

No requirement for immunosuppression

Better long-term insulin independence rates

Higher islet yield

Lower procedural risk

13. Which diagnostic test is the LEAST sensitive for detecting PTDM?

A1C

Post-lunch capillary blood glucose

Fasting plasma glucose (FPG)

2-hour oral glucose tolerance test (OGTT)

14. Which type of pancreas transplantation has the highest 5-year graft survival rate?

Simultaneous pancreas-kidney (SPK)

Pancreas after kidney (PAK)

Pancreas transplant alone (PTA)

Islet after kidney (IAK)

15. What is a concern when considering SGLT2 inhibitors in immunosuppressed transplant recipients?

Risk of genitourinary infections

Increased risk of rejection

Accelerated graft fibrosis

Interference with tacrolimus levels

16. What is the 15-year graft survival rate for simultaneous pancreas-kidney transplantation?

25%

62%

11%

40%

17. A 47-year-old man is undergoing distal pancreatectomy for a benign tumour. He has risk factors for diabetes including obesity and family history. Why might islet autotransplantation be particularly important for this patient?

It reduces the need for surgery

It guarantees lifelong insulin independence

It eliminates his risk factors for diabetes

It provides superior metabolic function which may be important in high-risk patients

18. A 35-year-old man with type 1 diabetes has marked glycemic lability and severe hypoglycemia despite optimal medical therapy including insulin pump and continuous glucose monitoring. He has preserved renal function with an eGFR of 85 mL/min. Which transplant options may be considered for this patient?

Islet allotransplantation or pancreas transplant alone

Simultaneous pancreas-kidney transplant only

Kidney transplant only

No transplant options are appropriate

19. A 45-year-old woman is being evaluated for pancreas transplantation. She asks about potential benefits on diabetic complications. Which statement best describes the effect of pancreas transplantation on diabetic nephropathy?

No effect on kidney disease

Immediate reversal of nephropathy within 6 months

Improvements in histological changes have been reported 5-10 years post-transplant

Worsening of kidney function due to immunosuppression

20. Why is pre-transplant screening for diabetes and CV risk factors recommended?

To identify people at high risk for developing PTDM

To reduce the need for post-transplant monitoring

To exclude all patients with diabetes from transplantation

To determine immunosuppression dosing

21. What percentage of patients undergoing total pancreatectomy will have meaningful glycemic benefit from islet autotransplantation?

More than 25%

More than 50%

More than 90%

More than 75%

22. A patient with PTDM has renal impairment with eGFR of 25 mL/min and a poorly functioning pancreas transplant. Which class of antihyperglycemic agents should be avoided in this patient?

DPP-4 inhibitors

Metformin

Insulin

Insulin secretagogues

23. A 55-year-old man developed PTDM 6 months after liver transplantation. He has mild renal impairment (eGFR 55 mL/min) and a BMI of 32 kg/m². He is currently on tacrolimus and low-dose prednisone. Which class of antihyperglycemic agents would be generally preferred as first-line therapy for this patient?

Insulin secretagogues

Agents that do not promote weight gain (e.g., metformin)

Sulfonylureas

Thiazolidinediones

24. What is the reported 5-year insulin independence rate with current islet transplantation protocols?

Up to 10%

Up to 60%

Up to 30%

Up to 85%

25. Post-transplant diabetes mellitus (PTDM) was previously known as:

Immunosuppression-associated diabetes (IAD)

New-onset diabetes after transplantation (NODAT)

Secondary transplant diabetes (STD)

Transplant-induced hyperglycemia (TIH)

26. What percentage of procedural complications occur with islet transplantation at experienced centres?

Less than 30%

Less than 5%

Less than 10%

Less than 20%

27. A 35-year-old man with type 1 diabetes has marked glycemic lability and severe hypoglycemia despite optimal medical therapy including insulin pump and continuous glucose monitoring. He has preserved renal function with an eGFR of 85 mL/min. What is a key benefit of islet transplantation even in the absence of complete insulin independence?

Elimination of all immunosuppression requirements

Complete reversal of diabetic nephropathy

Prevention of severe hypoglycemia and improved glycemic control

Permanent cure of type 1 diabetes

28. Through which route are islets infused during islet allotransplantation?

Intraperitoneal injection

Subcutaneous implantation

Portal vein into the liver

Intramuscular injection

29. Which risk factors for PTDM are specifically related to transplantation?

Age and family history of diabetes

Hepatitis C, CMV, corticosteroid dose, and choice of immunosuppressive medications

Central obesity and metabolic syndrome

Ethnicity and sedentary lifestyle

30. A 60-year-old man with pre-existing type 2 diabetes undergoes heart transplantation. Post-operatively, his blood glucose levels are significantly elevated. What is the recommended approach for glycemic management in the acute post-transplant setting?

Insulin therapy, which may be the preferred agent

No treatment until 3 months post-transplant

SGLT2 inhibitors as first-line

Continue oral agents only

31. A 48-year-old woman is 6 weeks post-kidney transplant and is taking prednisone as part of her immunosuppression regimen. You need to screen for hyperglycemia. What is the most sensitive and practical method to screen for hyperglycemia in this patient?

A1C

Fasting plasma glucose

Random plasma glucose

Post-lunch capillary blood glucose (around 4 pm)

32. A 38-year-old woman with chronic painful pancreatitis is scheduled for total pancreatectomy. She does not currently have diabetes. What procedure should be considered to prevent or ameliorate post-pancreatectomy diabetes?

Islet autotransplantation

Prophylactic metformin

Islet allotransplantation

Immediate initiation of insulin therapy

33. A 52-year-old man is 1 month post-kidney transplant. His fasting glucose is 5.8 mmol/L but his post-lunch glucose at 4 pm is 11.2 mmol/L. He has no symptoms of hyperglycemia. How should this finding be interpreted and managed?

Diagnose PTDM and start long-term oral therapy

Immediately reduce immunosuppression

Ignore as fasting glucose is normal

This may represent transient hyperglycemia; treat if needed and rescreen at 3 months

34. What is an advantage of considering PAK or IAK in patients with a functioning kidney transplant?

Eliminates the need for immunosuppression

No additional immunosuppression risk since already on immunosuppressants

Guarantees insulin independence

Reverses all microvascular complications

35. A patient is considering islet versus pancreas transplantation. Which statement correctly compares these options?

Both procedures have identical success rates

Islet transplantation has higher procedural risk than pancreas transplantation

Islet transplantation requires more immunosuppression than pancreas transplantation

Pancreas transplantation has more reliable and durable insulin independence

36. A 50-year-old man with type 1 diabetes received a successful kidney transplant 2 years ago. He continues to have severe hypoglycemia and glycemic lability despite optimal insulin therapy. Which transplant option should be considered for this patient?

Pancreas after kidney (PAK) or islet after kidney (IAK)

No additional transplant is indicated

Simultaneous pancreas-kidney transplant

Repeat kidney transplant

37. A 45-year-old woman with PTDM is being managed post-liver transplant. Her A1C is 8.2% on metformin alone. She has normal renal function. What small studies have suggested regarding DPP-4 inhibitors in PTDM?

They have shown efficacy and less weight gain compared to insulin glargine

They accelerate graft rejection

They are contraindicated in all transplant recipients

They cause significant drug interactions with tacrolimus

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