SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 25-year-old man presented to the emergency unit after a seizure episode. He had two previous episodes, but no investigation was done. Laboratory values were calcium 6.8 mg/ dl, phosphorus 7.0 mg/ dl, and PTH 70 pg/ml (reference range, 12-72 pg/ml). A diagnosis of autosomal dominant hypocalcemia type 1 was performed. Calcium and vitamin D were prescribed..
Question: Which ONE of the following is not a potential complication of this therapy?
A.        Nephrocalcinosis
B.        Brain calcifications
C.        Nephrolithiasis
D.        Hypocalciuria
Answer: D
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 72-year-old woman has CKD stage 5 (not yet on dialysis), hypertension, secondary hyperparathyroidism (PTH, 380 pg/ml; reference range, 10-65 pg/ml), and osteoporosis with a prior radial fracture. Her serum cal­cium is 7.8 mg/ dl, and phosphate is 3.9 mg/ dl. Her PCP contacts you for advice on adding calcimimetic or denosumab given her combination of CKD-MBD and osteoporosis..
Question: Which of the following is correct regarding drug-induced hypocalcemia?
A.        A recent meta-analysis reported that the risk of hypocalcemia is doubled in patients treated with calcimimetics compared with controls
B.        Denosumab rarely causes hypocalcemia in patients on hemodialysis
C.        High alkaline phosphatase levels are a risk factor for calcimimetic-induced hypocalcemia
D.        Denosumab has not been shown to be effective in kidney transplant recipients
Answer: C
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 62-year-old woman with ESKD has been receiving chronic hemodialysis for the last 3 years. Her PTH level has been increasing and has been between 900 and 1000 pg/ ml over the past 4 months. She has previously tried taking cinacalcet but could not tolerate it because of gastrointestinal side effects. You are contemplating prescribing etelcalcetide to this patient..
Question: Which ONE of the following is CORRECT given US data on new users of etelcalcetide?
A.        Patients who had previously used cinacalcet for secondary hyperparathyroidism (SHPT) without success are unlikely to receive a benefit from etelcalcetide, so other approaches to treating SHPT are advisable.
B.        Recipients of etelcalcetide who received the drug for a year experienced a decrease in PTH level of approximately 40% at 1 year.
C.        Circulating levels of phosphate tended to begin to decrease with etelcalcetide after approximately 4-6 months of sustained use.
D.        At any given time point in the first year of etelcalcetide use, approximately 8% of patients will have a corrected serum calcium level of < 7.5 mg/ dl.
Answer: B
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 48-year-old patient with CKD stage 4 secondary to diabetes is seen in clinic to discuss blood results, and he asks about the significance of his elevated PTH. You counsel the patient about the potential impact of developing SHPT, particularly its long-term implications for health..
Question: In studies of patients with CKD and ESKD, which ONE of the following is CORRECT?
A.        In observational data, a U-shaped association has been seen between PTH level with mortality, whereas patients with PTH > 1200 pg/ml had an approximately 11 % shorter lifespan than patients with PTH levels at goal.
B.        Development of SHPT is associated with increased major cardiovascular events and death
C.        Older age, female sex, and hypertension are pre­dictors of the development of SHPT
D.        Development of SHPT is not associated with increased risk of CKD progression
Answer: B
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

You are teaching a group of medical residents about the management of hyperphosphatemia in CKD. After discussing traditional phosphate binders, you move on to discuss newer agents and explain that there are multiple routes of phosphate absorption in the small intestine that can serve as targets for the treatment of hyperphosphatemia..
Question: Which ONE of the following hyperphosphatemia treatments primarily targets intestinal paracellular phosphate absorption?
A.        Tenapanor
B.        Modified-release nicotinamide
C.        EOS789
D.        Ferric iron oxide adipate
Answer: A
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 58-year-old man with ESKD secondary to type 2 diabetes has been receiving hemodialysis for 4 years. His serum phosphate levels have been > 7 mg/dl for the last several months despite dietary education and increasing his dose of phosphate binders. He has a well-functioning arteriovenous fistula and meets targets for adequate dialysis based on a 4-hour dialysis run. However, he cuts dialysis treatments short several times per month. You are reviewing his treatment regimen in an effort to improve phosphate control..
Question: Which of the following statements regarding phosphate clearance by hemodialysis is CORRECT?
A.         Nearly 80% of phosphate removal by hemodialysis occurs within the first hour of treatment.
B.        Intracellular phosphate concentrations are reduced by hemodialysis.
C.        Serum phosphate generally returns to predialysis concentrations within 12 hours of therapy.
D.        The length of hemodialysis treatment has little impact on the total amount of phosphate removal.
Answer: B
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 59-year-old man with ESKD on hemodialysis due to bilateral nephrectomy (first after motorcycle accident at age 30, second because of renal cell carcinoma at 53 years) presented for transplant evaluation. He has had four episodes of low-trauma fractures (wrist, arm, and leg). He described muscle weakness and difficulty with walking and bone pain, all which developed over the past year. He walks with a cane, for support. His blood tests revealed calcium 8.8 mg/ dl, phosphate 2.2 mg/dl, iPTH 380 pg/ml, 25-hydroxyvitamin D 33.8 ng/ml, alkaline phosphatase 70 U /L (normal for men is 45-115 U/L). Dual-energy x-ray absorptiometry (UXA scan) of femoral neck revealed a T-score of - 3 (osteoporosis diagnosis), and a whole-body bone scan revealed symmetrical uptake of the nucleotide in ribs..
Question: Which one of the following is the MOST CORRECT approach for this patient?
A.        The patient likely has osteoporosis and should have a steroid minimization protocol after the transplant, along with antiresorptive medication.
B.        The patient likely has osteoporosis and should have a steroid minimization protocol, and no antiresorptive medication will be needed.
C.        The patient likely has low bone turnover disease along with low bone volume, and, for this reason, the kidney transplant is contraindicated.
D.        Ideally, this patient should have a bone biopsy in order to identify the optimal therapy.
Answer: D
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 62-year-old man, with membranous nephropathy, underwent kidney transplantation 2 years ago. His kidney graft has good function (creatinine 1.3 mg/dl, CKD-EPI 58 ml/min per 1.73 m2), but he presents with chronic hypercalcemia (calcium 10.8 mg/dl), and high PTH level (iPTH, 520 pg/ml), with normal alka­line phosphatase and phosphate serum levels..
Question: Which ONE of the following is the most correct approach for this patient?
A.        Start an oral calcimimetic, because the patient has hypercalcemic hyperparathyroidism and high bone turnover
B.        Try to obtain a bone biopsy, because hypercalcemic hyperparathyroidism in kidney-transplant recipients commonly does not represent high bone turn­over but instead normal or low bone turnover
C.        Schedule a parathyroidectomy, because the patient has hypercalcemic hyperparathyroidism and high bone turnover
D.        Perform a DXA examination
Answer: B
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 57-year-old woman with ESKD in peritoneal dialysis had a traumatic fracture of her wrist. A DXA exam revealed a T-score of femoral neck of -2. Her rheumatologist wants to start therapy for osteoporosis. PTH is 58 pg/ml, calcium is 8.5 mg/dl, phosphorus is 4.8 mg/ dl, and alkaline phosphatase is 45 U /L (within normal range)..
Question: Which ONE of the following is the MOST CORRECT answer?
A.        Advise denosumab
B.        Advise a bisphosphonate
C.        Advise vitamin D supplementation
D.        Schedule a bone biopsy before starting therapy
Answer: D
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 72-year-old woman with history of hypertension for more than 20 years and diabetes mellitus type 2 diagnosed 12 years ago presented to the nephrology clinic, where she is followed for presumed diabetic nephropathy. Her physical examination reveals BP 144/80 mm Hg, with normal heart rate, and symmet­ric pitting edema in both legs. Her lab results showed a hemoglobin of 11.2 g/ dl, serum creatinine 3.7 mg/ dl and 24 hour urine protein determination of 1.6 g. Her medication consists of lisinopril 20mg day, dapagliflozin 10 mg, atorvastatin 20 mg, and subcutaneous insulin..
Question: Which one of the following is MOST correct?
A.        The nephrologist should be worried about mineral and bone-related parameters, as CKD-MBD is associated with poor outcomes
B.        The nephrologist should not be worried about mineral and bone-related parameters at this time, as the patient is not in stage 5
C.        Cardiovascular morbidity and mortality is similar across the different stages of CKD
D.        Evaluation of extraosseous calcifications is a better way to assess cardiovascular risk in CKD patients, compared to clinical history and/ or lab results
Answer: A
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 79-year-old woman with ESKD secondary to diabetes and hypertension fractured her hip while ambulating to a wheelchair after dialysis. She is dialyzed three times weekly. Her most recent PTH is 89 mg/ dl (range, 15--65 pg/ml), phosphorus is 4.9 mg/ dl (range 2.5-4.5 mg/ dl), and corrected calcium is 8.8 mg/ dl (range, 8.8-10.7 mg/ dl)..
Question: Which statement below is MOST correct?
A.        In her age group, the risk of fracture is the same for ESKD compared with non-ESKD patients
B.        The mortality risk for ESKD patients is the same after the fracture compared with mortality risk in non-ESKD patients after fracture
C.        Factors that increase fracture risk for ESKD patients include age and CKD-MBD and postmenopausal osteoporosis
D.        Length of hospital stay following the fracture is unlikely to be changed by her ESKD status
Answer: C
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 61-year-old postmenopausal woman has CKD stage 3 related to class IV lupus nephritis treated successfully with Cytoxan and glucocorticoids when she was 30 years old. She has mild hypertension and is taking lisinopril 20 mg daily, atorvastatin, and a multivitamin. PTH and phosphorus have always been in normal range. She has never been screened for osteoporosis because her nephrologist told her the results of common screening methods would be difficult to interpret. Her current PCP asks you for advice regarding screening..
Question: Which of the following statements is MOST accurate?
A.        There is little utility to screening by DXA because she likely has renal osteodystrophy, and DXA would not be sufficiently predictive of fracture risk.
B.        There is little utility to screening because the treatments for osteoporosis are contraindicated by her reduced eGFR
C.        DXA should be done, but clinical variables should also be assessed using the fracture risk assessment tool to increase the predictive capability of DXA.
D.        She should be screened by DXA as per general population screening guidelines.
Answer: D
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 72-year-old man has CKD stage 4 related to renovascular disease. He has coronary artery disease and is s/p ST elevation myocardial infarction, and s/p multiple angioplasties. He has peripheral vascular disease and severe chronic obstructive pulmonary disease. He has been taking glucocorticoids for years for chronic obstructive pulmonary disease. He has had a number of fractures, related to falls, and also has a nontraumatic vertebral fracture. He has been taking calcitriol for many years, but this was stopped when his PTH was noted to be < 100 pg/ml. Follow-up labs after stopping vitamin D receptor activator (VORA) show a low bone-specific alkaline phosphatase and PTH 120 pg/ml. Vitamin D levels are normal. Phosphorus is normal, and he is not taking phosphate binders. Calcium is normal at 9.8 mg/dl..
Question: Of the following, which is the best agent for his osteoporosis?
A.        Pamidronate
B.        Denosumab
C.        Teriparetide
D.        Romosozumab
Answer: C
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 59-year-old man has ESKD secondary to diabetes and is receiving dialysis three times weekly. He has hypertension and hyperlipidemia. He is noted to have osteoporosis on a routine screen. PTH is >1200 pg/dl while taking maximum-dose etalcalcetide and calcitriol. Bone­specific alkaline phosphatase is high. Vitamin D is normal, phosphorus is 5--6 mg/ dl, he is taking sevelamer 2400-mg three times a day, and calcium is normal..
Question: Which of the following agents is best for his osteoporosis?
A.        Alendronate
B.        Denosumab
C.        Teriparatide
D.        Parathyroidectomy
Answer: D
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

An 84-year-old woman with creatinine 1.8 mg/ dl is treated with denosumab following a low trauma vertebral fracture. Laboratory tests prior to treatment demonstrated PTH 286 pg/ml, vitamin D concentration 16 ng/ml, total calcium of 8.3 mg/dl, and phosphorus 4.7 mg/ dl. Laboratory tests were repeated 3 weeks later..
Question: What is the most likely adverse effect of denosumab to be observed on laboratory tests?
A.        Hypercalcemia
B.        Acute kidney injury
C.        Hypocalcemia
D.        Toxic levels of denosumab
Answer: C
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 54-year-old woman with type 2 diabetes mellitus, hypertension, obesity, atrial fibrillation, and end-stage kidney disease treated with peritoneal dialysis has developed an indurated area over right medial thigh. Her medications include glargine insulin, lispro insulin, sevelamer, warfarin, metoprolol, and lisinopril. Sites for insulin injections include abdominal wall and left lateral thigh. On physical examination, the skin over right medial thigh is not ulcerated but has severe tenderness with areas of purple discoloration..
Question: Which of the following medications is a potential risk factor for this presentation?
A.        Glargine insulin
B.        Lispro insulin
C.        Sevelamer
D.        Warfarin
E.        Metoprolol
Answer: D
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 62-year-old man with primary focal segmental glomerulosclerosis has been hemodialysis dependent for the past 6 years. He was recently hospitalized for abdominal pain, which was determined to be from sigmoid diverticulitis. His symptoms resolved upon medical management of diverticulitis that included antibiotic treatment, and he was discharged home. As you review his hospitalization course during dialysis rounds, you notice abdominal aortic calcification and bilateral iliac artery calcification on CT..
Question: Which of the following therapeutic approaches should be considered in this patient's management?
A.        A void hypercalcemia
B.        Induce hypophosphatemia
C.        Supplement vitamin K
D.        Sodium thiosulfate infusion
Answer: A
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 42-year-old man with persistent hypercalcemia from primary hyperparathyroidism is diagnosed with calciphylaxis involving his left calf. His kidney function and serum phosphorus are normal, and current medications include a multivitamin tablet and tramadol..
Question: Which of the following statements is MOST CORRECT regarding this patient's condition?
A.        Teriparatide should be immediately started
B.        The 1-year survival rate is likely higher in this patient compared to dialysis-dependent patients with end-stage kidney disease who develop calciphylaxis
C.        Calcitriol should be immediately started
D.        Sevelamer should be immediately started
Answer: B
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 61-year-old woman with type 2 diabetes mellitus and end-stage kidney disease treated with hemodialysis has been receiving wound care and sodium thiosulfate infusion treatments for right lower leg wound caused by calciphylaxis. The clinical team is considering starting hyperbaric oxygen therapy to facilitate wound healing..
Question: Which of the following is an absolute contraindication for hyperbaric oxygen therapy?
A.        Untreated pneumothorax
B.        Claustrophobia
C.        Sinus infection
D.        Diabetes mellitus
Answer: A
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 46-year-old woman with end-stage kidney disease underwent surgical debridement of nonhealing leg ulcer located above the left ankle. The patient has severe diabetic peripheral neuropathy and reports that pain intensity at the ulcer site has been mostly none to mild. The pathologist examining the cutaneous tissue obtained during surgical debridement raises a concern for calciphylaxis..
Question: Which of the following features on histology can help distinguish calciphylaxis from its mimics?
A.        Presence of circumferential calcium deposits in hypodermal vessels
B.        Presence of noncircumferential calcium deposits in hypodermal vessels
C.        Absence of thrombosis
D.        Presence of inflammatory infiltrate in cutaneous vessel walls
Answer: A
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 50-year-old man is consulting you because of recent diagnosis of a kidney stone. He was in a good state of heath until 1 week ago when he developed sudden and severe right-flank pain. He had no hematuria and no fever. A computed tomography (CT) scan of the abdomen without contrast revealed mild left hydroureter with an obstructing 4-mm stone at the left ureterovesical junction. Laboratory tests including serum creatinine and urinalysis were normal. In the emergency department, he received analgesics that relieved the pain temporarily, and he signed himself out against medical advice and got an appointment with you 3 days later. He has not passed any stone, and the pain persists when he does not take analgesics. He recalls having passed a kidney stone spontaneously about 10 years ago but has not had symptoms of colic since then until this most recent episode. He eats a high-protein diet and does a lot of exercise in the gym..
Question: What is the best advice at this point?
A.        Repeat blood tests and order a 24-hour urine collection for assessment of stone risk factors
B.        Advise him to go back to emergency department for urgent urologist consultation
C.        Start him with expulsive medical therapy (tamsulosin) and get a follow-up for him with a urologist over the next week to evaluate further therapy
D.        Advise him to drink plenty of water, move around, cut down the high-protein dietary intake, and return in 2 weeks
E.        Start him on antibiotics to prevent superimposed infection
Answer: C
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

You asked to see a 35-year-old man with recurrent nephrolithiasis since age 18. He has passed about 15 stones in his lifetime but has not had an episode of colic in the past 3 years. He has a strong family history of kidney stones on both sides of his family. He had removal of one kidney stone with lithotripsy a few years ago, but he is not sure about stone composition. He has taken thiazide diuretics in the past, but he discontinued them because "they made him urinate too much." He is currently asymptomatic. Physical examination is unremarkable. Serum creatinine is 1.1 mg/dl, calcium is 8.9 mg/dl, and total CO2 is 26 mmol/L. He has documented 24-hour urine collection of calcium at 360 mg/dl (normal, < 250 mg/dl). A CT scan of the abdomen shows no stones in the kidneys at present..
Question: What is the best course of action for this patient?
A.        Advise a low calcium intake in view of his hypercalciuria
B.        Perform a complete metabolic assessment, including 24-hour urine for calcium, oxalate, citrate, uric acid, and electrolytes, to establish mechanisms for his hypercalciuria
C.        Do nothing and follow up in a few months because there is no evidence of new formation of kidney stones over the past 3 years
D.        Advise against genetic testing as there are no indications for this
Answer: B
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 38-year-old obese woman presents with history of recurrent kidney stones. She is not aware of any other past or present significant medical problems. She recalls that previous clinicians found "too much uric acid" in a 24-hour urine collection done last year, but she did not go to follow-up appointments. There is no significant medical family history of kidney stones..
Question: Which ONE of the following is the best advice for this patient at this moment?
A.        Any interventions done to control obesity will be of benefit to prevent new stone formation
B.        All obesity surgical procedures have been found to be equally associated with tendency to form kidney stones
C.        Patient should be started on allopurinol
D.        A 24-hour urine collection for measuring stone risk factors is indicated to identify metabolic abnormalities that may need to be addressed
E.        Use of thiazide diuretics would be advisable at this point
Answer: D
Subject: Disorder of Divalent Ions Renal Bone Disease and Nephrolithiasis

A 56-year-old man with history of recurrent kidney stones is now referred to you because of the incidental findings of nephrocalcinosis. He was born in Iran and has been living in the United States since age 14 years. Family history is unknown. Physical examination is unremarkable. His serum calcium and serum bicarbonate levels are normal. His main concern is that his serum creatinine was 1.5 mg/ dl in 2019 and 1.7 mg/ dl in 2022. In the past, he has been advised to take potassium citrate, but he has difficulty tolerating it because of "chronic esophagitis." A CT scan shows two non-obstructing kidney stones in the right kidney measuring up to 5 mm..
Question: What is the best course of action for this patient at this moment?
A.        24-hour urine collection for measurement of stone risk factors and blood for genetic analyses
B.        Refer to a urologist for surgical management of his two kidney stones
C.        Refer to a nutritionist for detailed evaluation of his habitual dietary intake
D.        Assure him that nephrocalcinosis, despite its dramatic radiologic appearance, is a benign condition unlikely to progress to renal failure
Answer: A