Transplant pathology: chronic rejection: practice question

A Pathology question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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Pathology · Transplant pathology: chronic rejection

Sample item

A kidney transplant recipient two years after transplant has a slowly rising creatinine. Biopsy shows interstitial fibrosis and tubular atrophy with vascular changes. Which vascular lesion is characteristic of chronic rejection?

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

C. Graft arteriosclerosis with concentric fibro-intimal proliferation from chronic immune injury

Chronic rejection develops over months to years and is driven by alloantibody and T-cell mediated injury that stimulates smooth muscle proliferation. The hallmark is concentric intimal thickening of graft arteries (graft arteriosclerosis), with interstitial fibrosis and tubular atrophy. It is the leading cause of late graft loss and is seen in hearts as accelerated coronary disease.

Option by option

  • A. Fibrinoid necrosis of arterioles with neutrophils and thrombi

    Fibrinoid necrosis with neutrophils and thrombi describes hyperacute rejection from preformed antibodies.

  • B. Endotheliitis with subendothelial lymphocytes and acute tubulitis

    Endotheliitis and tubulitis describe acute cellular rejection within weeks to months.

  • C. Graft arteriosclerosis with concentric fibro-intimal proliferation from chronic immune injury (correct)

    Correct. Concentric intimal fibrosis of graft arteries marks chronic rejection.

  • D. Vacuolation of proximal tubular cells from calcineurin inhibitor toxicity

    Isometric vacuolation of tubular cells is a toxic effect of calcineurin inhibitors and does not involve concentric arterial intimal thickening.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

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Questions about this Pathology question

What is the answer to this Pathology question?

The best answer is C, Graft arteriosclerosis with concentric fibro-intimal proliferation from chronic immune injury. Chronic rejection develops over months to years and is driven by alloantibody and T-cell mediated injury that stimulates smooth muscle proliferation.

Why is "Fibrinoid necrosis of arterioles with neutrophils and thrombi" not the answer?

Fibrinoid necrosis with neutrophils and thrombi describes hyperacute rejection from preformed antibodies.

Why is "Endotheliitis with subendothelial lymphocytes and acute tubulitis" not the answer?

Endotheliitis and tubulitis describe acute cellular rejection within weeks to months.

Why is "Vacuolation of proximal tubular cells from calcineurin inhibitor toxi…" not the answer?

Isometric vacuolation of tubular cells is a toxic effect of calcineurin inhibitors and does not involve concentric arterial intimal thickening.

What concept does this question test?

It tests Transplant pathology: chronic rejection in Pathology. The hallmark is concentric intimal thickening of graft arteries (graft arteriosclerosis), with interstitial fibrosis and tubular atrophy. It is the leading cause of late graft loss and is seen in hearts as accelerated coronary disease.

How hard is this question?

We tag it as an application question: it asks you to use a fact on a patient or a finding. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Transplant pathology: chronic rejection?

Learn each disease as a bundle: cause, key histology, markers, and the clinical hallmark. Then use the flashcards and the other Pathology questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.