Updated: 7/11/2019


Review Topic
2 2
  • A 55-year-old-woman presents with nausea and yellowing of the skin to her primary care physician. Medical history is significant for a liver transplantation approximately 1.5 weeks prior to presentation. On physical examination there is scleral icterus and mild ascites. A liver biopsy shows lymphocytic infiltrates in the interstitium. (Acute rejection)
  • Transplantation is a process by which
    • cells, tissues, or organs (graft) from the donor are transplanted into a host (or recipient)
  • The immune system's ability to recognize and respond to foreign antigens bring challenges to transplantation
    • all transplant patients or on immunosuppressive agents which increases their risk of infection 
  • There are several types of grafts
    • autograft
      • tissue is moved from one location to another in the same person
        • e.g., skin graft and using the saphenous vein to replace a coronary artery
      • the graft will not be considered foreign and will not require lifelong immunosuppresion
    • syngeneic graft (isograft)
      • tissue is transplanted from one genetically identical donor to the host
        • e.g., transplantation between monozygotic twins
    • allograft
      • tissue is transplanted from one genetically different donor of the same species to the host
        • e.g., kidney transplant
    • xenograft
      • tissue is transplanted from a donor of a different species to the host
        • e.g., porcine heart valve
Transplant Rejection
Transplant Rejection
Rejection Type
  • Type II hypersensitivity reaction where 
    • pre-existing recipient antibodies attack the donor antigen resulting in
      • complement activation
      • endothelial damage
      • inflammation
      • thrombosis
  • Time
    • minutes to hours
  • Findings
    • capillary thrombosis which
      • prevents graft vascularization
  • Cellular rejection
    • type IV hypersensitivity reaction where
      • recipient CD8+ T-cells react to donor antigens after activation by antigen presenting cells 
  • Humoral rejection
    • just like in hyperacute rejection; however,
      • the antibodies are formed after transplantation occured
  • Time
    • weeks to months
  • Findings
    • graft vessel vasculitis with
      • lymphocytic infiltrates
  • Treatment
    • Renal 
      • Continue calcineurin inhibitors (i.e., tacrolimus, cyclosporine) and add IV steroids
  • Type II and IV hypersensitivity reaction secondary to
    • CD4+ T-cells responding to the host's antigen presenting cells
  • Time
    • months to years
  • Findings
    • cytokine secretion after T-cell activation leads to
      • smooth muscle proliferation
      • interstitial fibrosis
      • parenchymal atrophy
Graft-versus-host disease
  • Type IV hypersensitivity reaction secondary to
    • the donor's T-cells attacking the recipient's cells leading to 
      • organ dysfunction
  • Time
    • variable
  • Findings
    • maculopapular rash
    • jaundice
    • diarrhea
    • hepatosplenomegaly
Tissue Compatibility Testing
  • ABO blood typing
  • Tissue typing
    • used to see if HLA antigens match and subtypes include
      • HLA-A
      • HLA-B
      • HLA-DR



Please rate topic.

Average 5.0 of 1 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M2.RH.14.141) A 37-year-old woman with a history of a kidney transplant presents with a cough, fever, and fatigue. Her symptoms started 1 week ago and have been steadily worsening. She has a history of IV drug use and worked in the past as a commercial sex work in her 20's. She recently traveled to Malasia 1 month ago. Her temperature is 101°F (38.3°C), blood pressure is 114/64 mmHg, pulse is 110/min, respirations are 19/min, and oxygen saturation is 93% on room air. Her physical exam is notable for bilateral coarse breath sounds. Laboratory values are ordered as seen below.

Na+: 140 mEq/L
Cl-: 102 mEq/L
K+: 4.7 mEq/L
HCO3-: 22 mEq/L
BUN: 30 mg/dL
Glucose: 96 mg/dL
Creatinine: 1.5 mg/dL (baseline 1.4 mg/dL)
Ca2+: 9.1 mg/dL

A chest radiograph is obtained as seen in Figure A and a CT scan of the chest is obtained as seen in Figure B. Which of the following is the most likely predisposing risk factor for this patient's presentation?
Review Topic | Tested Concept

QID: 104147





IV drug use








Transplant rejection







L 4 E

Select Answer to see Preferred Response

Topic COMMENTS (13)
Private Note