Transplant Surgery Practice Cases by Domain

Recipient-candidacy conference

A medically complex candidate has competing transplant benefit and perioperative risk. Define indication, contraindications, optimization, psychosocial and adherence assessment, alternatives, timing, and the threshold to list, defer, or decline.

Marginal organ offer

A high-urgency recipient receives an organ with quality, anatomy, ischemia, or transmissible-risk concerns. Decide whether to accept, what consent is required, how technique and monitoring change, and when decline is safer.

Early graft dysfunction

The graft is not functioning as expected. Use timing and organ-specific physiology to separate technical, hemodynamic, ischemic, immunologic, infectious, toxic, recurrent, and systemic causes.

Adherence and stewardship

A recipient has repeated missed medication or follow-up. Address barriers, capacity, substance use or mental health where relevant, support, graft risk, fairness, communication, and a safe treatment plan without stigmatizing language.

Ethics and allocation

A conflict arises around urgency, utility, donor risk, living-donor autonomy, retransplantation, or limited resources. Apply current policy, justice, transparency, consultation, and patient-centered communication.

Sensitized candidate and organ offer

Interpret antibody history, donor-specific antibody, crossmatch, prior transplant, organ urgency, desensitization or avoidance, induction, consent, monitoring, and treatment contingency.

Acute graft dysfunction with competing infection

Use organ function, timing, imaging, microbiology, drug exposure, antibodies, and biopsy to distinguish rejection from infection or technical disease before escalating immunosuppression.

Biopsy pattern and mechanism

Interpret an organ-specific pattern using current classification, identify the likely mechanism, request complementary testing, choose treatment, and state response monitoring and adverse effects.

Chronic allograft injury

Address adherence, antibody exposure, recurrent disease, medication toxicity, structural complications, cardiovascular/metabolic risk, prognosis, retransplant planning, and goals of care.

Immunosuppression redesign

Modify induction or maintenance for infection, malignancy, renal dysfunction, cytopenia, pregnancy, intolerance, recurrence, or adherence while protecting the graft.

DBD procurement planning

Review donor stability, organ assessment, allocation, team coordination, anatomy, cannulation, cross-clamp, preservation, injury avoidance, packaging, and communication.

DCD pathway

Define withdrawal and declaration boundaries, functional warm ischemia, team roles, consent and ethics, organ assessment, rapid recovery, preservation, and acceptance implications.

Living-donor evaluation

Protect autonomy, voluntariness, confidentiality, medical and psychosocial safety, anatomy, remnant function or volume, recipient alternatives, and independent advocacy.

Unexpected procurement injury

Identify vascular, ductal, ureteral, pancreatic, intestinal, or parenchymal injury; communicate it; determine repair, altered technique, consent, or decline; and document appropriately.

Donor-derived disease signal

Coordinate testing, prophylaxis or treatment, recipient disclosure, reporting, organ-partner communication, surveillance, and immunosuppression adjustment.

Candidate with high immunologic and vascular risk

Balance transplant benefit, sensitization, crossmatch, iliac anatomy, cardiovascular risk, dialysis alternatives, organ offer, induction, operative plan, and surveillance.

Kidney implantation with multiple vessels

Describe back-table strategy, recipient vessel selection, anastomotic sequence, ischemic-time priorities, reperfusion, ureteral reconstruction, endpoint, and bailout.

Delayed graft function

Use hemodynamics, urine output, Doppler, obstruction, ischemia-reperfusion injury, nephrotoxins, rejection, infection, biopsy timing, dialysis, and immunosuppression management.

Early vascular or urologic complication

Recognize thrombosis, stenosis, kinking, compression, leak, obstruction, lymphocele, or bleeding; choose imaging; intervene or explore; and protect renal function.

Late dysfunction

Evaluate chronic antibody-mediated injury, recurrent disease, calcineurin toxicity, obstruction, infection, adherence, malignancy, cardiovascular risk, and retransplant planning.

Listing and timing

Address acute or chronic liver failure, transplant benefit, cardiopulmonary and renal risk, infection, malignancy, psychosocial readiness, living/deceased options, and delisting thresholds.

Complex organ acceptance

Balance donor age and quality, steatosis, DBD/DCD pathway, anatomy, infection and malignancy risk, ischemia, recipient urgency, size, and operative capability.

Liver transplantation with portal thrombosis

Describe hepatectomy, venous strategy, thrombectomy or alternate portal inflow, reperfusion, arterial and biliary reconstruction, flow endpoints, and bailout.

Early graft failure

Distinguish hepatic-artery thrombosis, portal or outflow obstruction, primary nonfunction, bleeding, biliary issue, rejection, infection, and systemic/cardiac causes; state retransplant pathway.

Biliary complication or recurrence

Choose imaging and intervention, define endoscopic/interventional/operative options, manage infection and immunosuppression, and address recurrent liver disease or malignancy.

Candidate selection

Define diabetes phenotype, renal status, cardiovascular and peripheral vascular risk, obesity, adherence, surgical history, and choice among simultaneous pancreas-kidney, pancreas after kidney, or pancreas alone.

Donor and graft selection

Assess donor age and quality, hemodynamics, anatomy, pancreas injury, preservation, thrombosis risk, duodenal integrity, and whether graft use is justified.

Implantation

Describe back-table Y-graft or vascular reconstruction, portal venous strategy, graft orientation, arterial and venous anastomoses, reperfusion, enteric drainage, endpoint, and thrombosis prevention.

Early deterioration

Distinguish graft thrombosis, pancreatitis, bleeding, enteric leak, infection, rejection, obstruction, and systemic illness; state threshold for exploration and graft pancreatectomy.

Long-term care

Address glycemic outcome, renal function, rejection, infection, immunosuppression toxicity, recurrent autoimmunity, malignancy, adherence, and quality of life.

Intestinal failure and listing

Define anatomy, rehabilitation potential, parenteral-nutrition complications, liver disease, vascular access, infection, quality of life, psychosocial readiness, and graft type.

Operative planning

Describe graft composition, prior abdominal surgery, vascular inflow and outflow, recipient exenteration, proximal/distal reconstruction, stoma or surveillance access, abdominal closure, and bailout.

Nutrition and fluid management

Address graft function, enteral advancement, parenteral support, high-output losses, electrolytes, line safety, rehabilitation, and long-term autonomy.

Rejection and surveillance

Use endoscopy, biopsy, clinical trajectory, graft function, immunology, infection exclusion, and treatment monitoring.

Complex complications

Manage ischemia, leak, obstruction, infection, graft-versus-host disease, PTLD, abdominal compartment problem, graft failure, explantation, and retransplantation.

Time-dependent infection

Integrate timing, prophylaxis, net immunosuppression, exposures, donor-derived risk, devices, organ, source control, antimicrobial strategy, and immune adjustment.

Donor-derived event

Recognize unexpected infection or malignancy, stabilize and treat, test recipient, notify required parties, communicate with organ partners, disclose, report, and plan surveillance.

PTLD and malignancy

Establish tissue diagnosis and extent, reduce immunosuppression deliberately, use disease-specific therapy, protect graft function, and maintain long-term skin and organ surveillance.

Systemic toxicity

Address kidney injury, hypertension, diabetes, dyslipidemia, obesity, cardiovascular disease, bone disease, neurotoxicity, cytopenias, drug interactions, and medication burden.

Adherence, pregnancy, and life-course care

Evaluate barriers and support, preserve reproductive and fetal safety, coordinate medications, address transition and health maintenance, and balance patient goals with graft risk.