SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Chronic Kidney Disease



A 79-year-old man has CKD stage 4 in the setting of poorly controlled diabetes. He has coronary artery disease and is status post myocardial infarction with reduced ejection fraction. He has severe peripheral vascular disease, is status post right-sided below-the-knee amputation, and has a gangrenous toe on his left foot..
Question: Which adverse event is he MOST LIKELY to experience as result of SGLT2 inhibitor use?
A.        Volume overload
B.        Myocardial infarction
C.        Lower extremity amputation
D.        Dialysis
Answer: C
Subject: Chronic Kidney Disease



You are asked to evaluate a 56-year-old man with CKD. He has had diabetes and hypertension for 25 years. His medications include metoprolol, amlodipine, and metformin. On examination, his BP is 146/92 mm Hg but is otherwise unremarkable. His laboratory results show a urine ACR of 2000 mg/g, serum creatinine of 3.9 mg/dl, and eGFR of 17 ml/min per 1.73 m2. As you are discussing options for renal replacement therapy, he asks about whether his kidney disease could have been detected earlier. Screening for albuminuria is suggested for patients with diabetes, hypertension, GFR < 60 ml/min per 1.73 m2, and cardiovascular disease..
Question: What proportion of patients with diabetes in the United States undergoes annual urine ACR screening?
A.        5%–15%
B.        35%–55%
C.        65%–85%
D.        90%–100%
Answer: B
Subject: Chronic Kidney Disease



Screening for albuminuria has been recommended for individuals with hypertension by the 2017 American College of Cardiology/American Heart Association Hypertension Guidelines. The Board of Trustees at your local hospital asks you if most medical practices are compliant with these guidelines..
Question: What proportion of patients with hypertension and no diabetes in the United States undergoes ACR screening?
A.        < 10%
B.        20%–30%
C.        40%–50%
D.        60%–70%
Answer: A
Subject: Chronic Kidney Disease



You are asked to consult on a 63-year-old man with eGFR 58 ml/min per 1.73 m2 after a nephrectomy for renal cell carcinoma. He asks you what his chances are of ending up on dialysis..
Question: Which of the following CKD stages is NOT considered very high risk for CKD progression?
A.        CKD G3aA3
B.        CKD G3bA1
C.        CKD G3bA2
D.        CKD G4A1
Answer: B
Subject: Chronic Kidney Disease



You are interviewed by a local news station after a demonstration about inequality in health care occurred outside your hospital. You are asked whether the estimation of kidney function should be the same for all Americans regardless of race..
Question: Which effect would replacing the CKD-EPI 2009 equation with the CKD-EPI 2021 equation have on CKD prevalence in the United States?
A.        Prevalence would increase among White adults and decrease among Black adults
B.        Prevalence would decrease among White adults and increase among Black adults
C.        Prevalence would be stable among White adults and decrease among Black adults
D.        Prevalence would be stable among White adults and increase among Black adults
Answer: B
Subject: Chronic Kidney Disease



A large group practice is incorporating risk prediction algorithms to their electronic medical record. Currently, all patients are screened at their initial visit with a serum creatinine/eGFR and urine ACR. The group wishes to identify patients who have a normal eGFR but are at risk of developing kidney disease such that they can be followed more closely..
Question: Which of the following risk tools would be appropriate to use in a population with GFR > 60 ml/min per 1.73 m2?
A.        4-variable kidney failure risk equation
B.        8-variable kidney failure risk equation
C.        Advanced CKD risk tool
D.        Incident CKD risk tool
Answer: D
Subject: Chronic Kidney Disease



You are evaluating a 69-year-old patient with diabetes, hypertension, an eGFR of 52 ml/min per 1.73 m2, and albuminuria of 1800 mg/g who undergoes a kidney biopsy..
Question: Which of the following features on kidney biopsy was NOT associated with risk of CKD progression in the Boston Kidney Biopsy Cohort?
A.        Interstitial ﬁbrosis/tubular atrophy
B.        Arterial sclerosis/arteriolar sclerosis
C.        Global glomerulosclerosis
D.        Fibrinoid necrosis
Answer: D
Subject: Chronic Kidney Disease



You are rounding with a medical student who asks what new imaging technologies are available in the evaluation of kidney disease..
Question: Which of the following is an incorrect pairing of imaging modality and detectable morphology or functional assessment?
A.        Cationic ferritin-enhanced (CFE)-magnetic resonance imaging (MRI): glomerular number
B.        Point-of-care ultrasonography (POCUS): inﬂammation
C.        Diffusion-weighted MRI: ﬁbrosis
D.        Blood oxygenation level–dependent (BOLD) MRI: cortical tissue hypoxia
Answer: B
Subject: Chronic Kidney Disease



You are asked to evaluate a 39-year-old woman with nephrotic range proteinuria and normal eGFR. Laboratory tests PLA2R antibody, ANCA, antinuclear antibodies, anti-dsDNA, complement C3/C4, HIV, hepatitis C virus, and hepatitis B virus are all negative. She does not wish to undergo biopsy. She asks if there are additional laboratory tests that can be pursued..
Question: Which of the following has not been identiﬁed as an autoantigen in primary membranous nephropathy?
A.        EXT1/EXT2
B.        TNFR1
C.        Sema 3B
D.        NELL-1
Answer: B
Subject: Chronic Kidney Disease



You are asked to evaluate a 21-year-old man who presents with multiple cysts in both kidneys. His eGFR is normal and he does not have proteinuria or hematuria. He does not have a family history of known polycystic kidney disease or ESKD. His parents, who have accompanied him to the visit, ask whether a kidney biopsy or genetic screening would be most appropriate..
Question: Genetic testing is expected to have the highest diagnostic yield in which of the following kidney dis-ease phenotypes?
A.        Diabetic kidney disease
B.        Glomerulopathy
C.        Tubulointerstitial disease
D.        Congenital or cystic kidney disease
Answer: D
Subject: Chronic Kidney Disease



You are evaluating a 29-year-old man who presented with 4 g of albuminuria and normal eGFR. He mentions that an older sibling has a kidney transplant and two cousins have albuminuria. His father died from an accident when the patient was very young. His mother does not visit doctors often but has never been told there was a problem with her kidneys. You discuss genetic screening with him and he asks you what you are most likely to ﬁnd..
Question: Apart from APOL1, variants in which gene family are the most common genetic ﬁnding in populations with FSGS?
A.        COL4A
B.        UMOD
C.        NPHP
D.        Cubilin
Answer: A
Subject: Chronic Kidney Disease



A 65-year-old woman with high BP and obesity presents to the CKD clinic. She has stage 4 CKD A2 and denies any complaints of headaches, edema, and shortness of breath. Her medications include torsemide, losartan, atorvastatin, and aspirin. Her BP is 155/68 mm Hg when sitting comfortably but is not performed in a standardized method with an oscillometric BP device. A resident assisting you in clinic suggests addition of amlodipine but the patient refuses. She is insistent that her home BP is better and she has always had “white-coat hypertension”. To solve the problem, you suggest ambulatory BP monitoring (ABPM)..
Question: Which ONE of the following is true regarding BP monitoring?
1. Most guidelines (including Kidney Disease: Improving Global Outcomes) recommend treatment of hypertension on the basis of ofﬁce-measured nonstandardized BPs in adults with CKD
B.        ABPM proﬁles reveal white-coat hypertension in the majority of patients
C.        White-coat hypertension is associated with increased risk of kidney outcomes, cardiovascular outcomes, and mortality
D.        The presence of masked uncontrolled hypertension, identiﬁed by ABPM, is associated with higher risk of composite cardiovascular and renal outcomes compared with participants with con-trolled BP
Answer: D
Subject: Chronic Kidney Disease



A 72-year-old man with type 2 diabetes mellitus, high BP, CKD 4 A3 with estimated eGFR 24 ml/min per 1.73 m2 presents to your CKD clinic for follow-up. He is maintained on losartan 100 mg, amlodipine 5 mg, atorvastatin 80 mg, and aspirin. His automated BP measured in clinic is 116/68 mm Hg. He appears perturbed as he was recently told by another practitioner to discontinue losartan given advanced CKD but is quite hesitant to make any medication changes..
Question: Which ONE of the following statements is true?
A.        Renin-angiotensin system (RAS) inhibitors should be stopped with eGFR < 30 ml/min per 1.73 m2 owing to risk of hyperkalemia
B.        Excessively tight BP control may be associated with worsening GFR, and his medications should be titrated to a target BP of > 130/80 mm Hg
C.        Compared with continuing RAS inhibition, stop-ping this therapy is associated with a higher absolute risk of death and major adverse cardio-vascular events in patients with CKD 4
D.        In a study comparing new users of dihydropyridine calcium channel blockers (DHP-CCB) versus RAS inhibitors in subjects with CKD G4–5 not on dialysis, there was a signiﬁcantly lower risk of major adverse cardiovascular event and mortality in patients taking DHP-CCB
Answer: C
Subject: Chronic Kidney Disease



A 60-year-old woman with diabetes mellitus, CKD 3B/A3, urinary ACR 500 mg/g, GFR 32 ml/min per 1.73 m2, hypertension, coronary artery disease, and heart failure with preserved ejection fraction presents to the clinic for a new consultation. She is maintained on lisinopril 40 mg, metformin 500 mg twice a day, atorvastatin 40 mg, and carvedilol 25 mg twice a day. Her BP checked in ofﬁce is 110/66 mm Hg and she offers no new complaints..
Question: Which of the following statements regarding SGLT2 inhibition is true?
A.        SGLT2 inhibitors should not be initiated at GFR < 35 ml/min per 1.73 m2
B.        SGLT2 inhibition does not confer any additional kidney beneﬁt in patients already on angiotensin-converting enzyme inhibitor therapy
C.        Metformin should be dose reduced or stopped if SGLT2 inhibitor is added
D.        In the DAPA-CKD trial, the renal beneﬁts were consistent across the spectrum of eGFR, albuminuria, and the presence/absence of diabetes mellitus
Answer: D
Subject: Chronic Kidney Disease



A 51-year-old man with CKD 3B secondary to IgA nephropathy, eGFR 40 ml/min, and urine ACR 560 mg/g attends for follow-up. He also has diabetes mellitus, is being treated with semaglutide with a recent HbA1c of 7%, and has a family history of colon cancer. He has not yet had a ﬁrst colonoscopy. His BP is at goal on full dose angiotensin II receptor blocker and chlorthalidone 50 mg every day..
Question: Which of the following is correct in considering treatment with an SGLT2 inhibitor in this patient?
A.        SGLT2 inhibitors have not been shown to be safe or effective in patients with glomerular disease such as IgA nephropathy
B.        He is at high risk of hypoglycemia unless his semaglutide is dose reduced or stopped
C.        He can safely continue his SGLT2 inhibitor while he takes his bowel preparation for colonoscopy
D.        Chlorthalidone dose may need to be reduced with the initiation of an SGLT2 inhibitor
Answer: D
Subject: Chronic Kidney Disease



A 56-year-old woman with CKD 4, eGFR 25 ml/min per 1.73 m2, ACR 480 mg/g, hypertension, and heart failure with preserved ejection fraction presents to the CKD clinic for follow-up. Despite taking oral iron, her hemoglobin has been trending lower in recent months, and in today’s laboratory results her hemoglobin is 9.2 g/dl. She reports some fatigue and reduced exercise tolerance, but has been reluctant to start erythropoiesis-stimulating agents because of needle phobia. She has read about new oral agents being developed for treatment of anemia of CKD..
Question: Which ONE of the following statements regarding anemia management in non-dialysis-dependent CKD is true?
A.        Hypoxia-inducible factor-prolyl hydroxylase inhibitors (HIF-PHIs) lead to increase in ferritin and hepcidin
B.        HIF-PHIs lead to decreases in hepcidin and total iron-binding capacity, and increases in ferritin
C.        In randomized controlled studies, vadadustat and daprodustat were noninferior to darbepoetin in achieving a mean change in hemoglobin from baseline to end of study
D.        Vadadustat was noninferior to darbepoetin alpha in analysis of the primary safety outcome (time to ﬁrst major adverse cardiovascular event)
Answer: C
Subject: Chronic Kidney Disease



You are discussing newer therapies to slow CKD progression with your in-patient rounding team. The intern asked about newer agents, namely the nonsteroidal mineralocorticoid receptor (MR) antagonist ﬁnerenone..
Question: Which ONE of the following statements is true?
A.        Finerenone is less potent in blocking MR cofactor binding as compared to agents such as spironolactone
B.        Finerenone is associated with reduction in the urinary ACR from baseline in patients on maximal doses of renin-angiotensin system inhibitors
C.        Large studies of ﬁnerenone have demonstrated improved cardiovascular outcomes, but have not shown beneﬁt in a composite renal outcome, comprising a decrease greater than or equal to 40% in eGFR or renal death
D.        Finerenone is not associated with hyperkalemia
Answer: B
Subject: Chronic Kidney Disease



A 50-year-old man with CKD 3b/A3, eGFR 45 ml/min per 1.73 m2, ACR 360 mg/g, and hypertension presents to the CKD clinic for follow-up. He is interested in advice regarding lifestyle modiﬁcations to slow CKD progression..
Question: Which ONE of the following statements regarding lifestyle modiﬁcation in management of nondialysis-dependent CKD is true?
A.        Recent meta-analysis found that lower dietary potassium intake was associated with signiﬁcantly decreased odds of CKD
B.        Healthy dietary pattern with higher intake of fruits, vegetables, whole grains, and ﬁber was associated with a reduced risk of hypertension and improved survival but there was no improvement in renal outcomes
C.        Current smokers have signiﬁcantly increased odds of CKD compared with former and never smokers
D.        Higher levels of activity, deﬁned as exercise of at least 30 minutes a day, is associated with lower odds of CKD
Answer: D
Subject: Chronic Kidney Disease



A 46-year-old woman with CKD G3b, eGFR 32 ml/min per 1.73 m2, secondary to diabetic nephropathy comes to the clinic. Her BP remains above goal at 144/92 mm Hg and she has persistent proteinuria of 2.7 g/g on a spot urine PCR. She is currently on valsartan 160 mg daily, chlorthalidone 50 mg daily, and carvedilol 25 mg twice a day. At prior visits, her potassium has been in the high normal range, 5.2–5.5 mEq/L, despite efforts at dietary control. You would like to increase her valsartan, and discuss adding a potassium-binding resin to her regimen..
Question: Which ONE of the following statements regarding novel potassium binders is true?
A.        Sodium Zirconium Cyclosilicate (ZS-9/SZC) is a non-absorbed highly selective inorganic cation, which binds K+ throughout the gastrointestinal tract in exchange for Ca2+
B.        Patiromer is associated with increased sodium load
C.        Sodium Zirconium Cyclosilicate (ZS-9/SZC) has a slow onset of action (within 12 hours)
D.        Sodium Zirconium Cyclosilicate (ZS-9/SZC) also can help improve acidosis
Answer: D
Subject: Chronic Kidney Disease



A 68-year-old man with diabetes mellitus, CKD 4/A3, urinary ACR 500 mg/g, GFR 28 ml/min per 1.73 m2, hypertension, coronary artery disease, and heart failure with preserved ejection fraction presents to the clinic for follow-up. The patient is maintained on lisinopril 40 mg, atorvastatin 40 mg, andcarvedilol25mg twice a day. His BP checked in ofﬁce is 118/70 mm Hg and he has no new complaints. Laboratory parameters are stable with the exception of serum bicarbonate level of 19 mEq/ml..
Question: Which of the following statements regarding management of metabolic acidosis is true?
A.        In a study of CKD patients followed for > 6 months, treatment with veverimer was associated with improvements in objective measurements of physical function
B.        In a study to assess the tolerability of sodium bicarbonate, treatment with 0.8 mEq per lean body weight per day was associated with more adverse events than 0.5 mEq per lean body weight per day and placebo
C.        Alkali therapy has not been associated with delayed CKD progression
D.        Studies of alkali therapy have demonstrated the safety and efﬁcacy of sodium bicarbonate even in those with advanced heart failure
Answer: A
Subject: Chronic Kidney Disease



A 34-year-old woman with a history of diabetes and CKD G3 A2 comes to clinic for review. She is currently taking lisinopril 40 mg daily, chlorthalidone 50 mg daily, and amlodipine 10 mg daily. She checks her BP at home twice weekly and brings readings ranging from 126/84 to 142/88 mm Hg. Her clinic reading today is 138/90 mm Hg. You express concern that her BP is above goal and begin to discuss escalation of her medications. She is reluctant, saying “I had a coffee this morning, and I’m always racing to get here on time”..
Question: When considering treating blood pressure to target levels, which of the following is correct?
A.        Current Kidney Disease: Improving Global Outcomes guidelines state that BP readings taken in the home or in a clinical setting should be used to guide treatment
B.        Observational studies have shown a good correlation between BPs obtained in a usual clinical visit versus those measured using a standardized measurement protocol
C.        Implementation of standardized BP measurements in an outpatient nephrology clinic would not require any signiﬁcant changes to typical workﬂow
D.        Patients should void urine before having their BPs measured
Answer: D
Subject: Transplantation

A 24-year-old man is evaluated 5 years after receiving a deceased donor kidney transplant. He is doing well and is asymptomatic. His medications include tacrolimus, mycophenolate mofetil, prednisone, omeprazole, trimethoprim/sulfamethoxazole, and acyclovir. On physical examination, the BP is 130/84 mm Hg. The allograft is nontender and without bruit. He has no apparent lower limb edema. The remainder of the examination results are normal. Laboratory studies show sodium of 136 mEq/L, potassium of 3.8 mEq /L, chloride of 112 mEq/L, total CO2 of 17 mmol/L, BUN of 30 mg/dl, creatinine of 1.8 mg/dl (increased from 1.4 mg/dl 1 month ago). Anti-HLA antibody testing shows the presence of a DQ7 donor-speciﬁc antibody with mean ﬂuorescence intensity of 12,000 (never previously detected before or after transplantation). A 12-hour tacrolimus trough level is 3 ng/ml (previous level was 3.8 ng/ml 1 month ago). The urinalysis shows no glucose and no protein, blood, or ketones. An ultrasound of the kidney transplant shows normal vasculature and no hydronephrosis..
Question: In addition to ongoing close follow-up of this man’s kidney function, which ONE of the following is the MOST appropriate management?
1. Perform a kidney allograft biopsy
2. Assess for donor-derived cell-free DNA
3. Calculate eplet mismatch score
4. Increase tacrolimus
Answer: A
Subject: Transplantation

A 54-year-old woman with a history of type 1 diabetes mellitus is admitted for management of suspected allograft rejection after undergoing living related kidney transplantation 2 years ago. Her medications include insulin as part, tacrolimus, mycophenolate mofetil, trimethoprim-sulfamethoxazole, valganciclovir, and bisoprolol. Physical examination results are unremarkable. The BP is 130/64 mm Hg supine. The allograft is non-tender and does not have a bruit. Laboratory studies show sodium of 143 mEq/L, potassium of 4.9 mEq/L, BUN of 35 mg/dl, creatinine of 1.6 mg/dl (increased from 1.2 mg/dl 2 weeks ago), and glucose of 260 mg/d. The tacrolimus trough is increased at 8 ng/ml. The urinalysis shows speciﬁc gravity of 1.015, 1+ glucose, and 21 protein, no blood or ketones. The allograft biopsy specimen shows glomerulitis (g1) and peritubular capillaritis (ptc 1), and C4d staining is negative. There is also evidence of early chronic interstitial ﬁbrosis and vascular injury (ct1, ci1, ah1, cv2)..
Question: In addition to ongoing close follow-up of this woman’s kidney function, which ONE of the following is the MOST appropriate management?
1. Assess for donor-derived cell-free DNA
2. Assess for donor-speciﬁc antibodies
3. Introduce an angiotensin-converting enzyme inhibitor
4. Assess for urinary chemokines
Answer: B
Subject: Transplantation

A 72-year-old man is evaluated 1 year after transplantation of a living donor kidney. He is doing well and has no symptoms. His medications include tacrolimus, azathioprine, omeprazole, aspirin, apixaban, trimethoprim/sulfamethoxazole, acebutolol, amiodarone, and amlodipine. There have been no complications during the ﬁrst year after transplantation; no rejection episode, no urinary tract infection, and no malignancies. The 3-month biopsy specimen was strictly normal. On physical examination, the BP is 145/103 mm Hg, the allograft is nontender, and there is no apparent edema. Lab-oratory studies show sodium of 141 mEq/L, potassium of 3.9 mEq/L, chloride of 116 mEq/L, total CO2 of 20 mmol/L, BUN of 26 mg/dl, creatinine of 1.2 mg/dl (baseline creatinine is 1.1–1.3 mg/dl). Donor-speciﬁc antibody screening results are negative at day 0 and 3, 6, and 12 months after transplantation. A 12-hour tacrolimus trough level is 7.5 ng/ml. The urinalysis shows no glucose, protein, blood, or ketones. An ultrasound of the kidney transplant is normal. You decide to not per-form the 1-year protocol allograft biopsy because of increased risk of bleeding complications in a patient using aspirin and oral anticoagulants..
Question: Which ONE of the following would be the MOST appropriate alternative for the allograft protocol biopsy?
1. Assess for non-HLA antibodies
2. Assess for cytomegalovirus viremia
3. Assess for C-reactive protein
4. Assess for donor-derived cell-free DNA
Answer: D
Subject: Transplantation

A 38-year-old woman is evaluated 3 months after an episode of acute antibody-mediated rejection, which occurred 2 years after receiving a deceased donor kidney transplant. Her medications include tacrolimus, mycophenolate mofetil, prednisone, trimethoprim sulfamethoxazole, valganciclovir, and nomegestrol acetate. The allograft biopsy performed 3 months ago showed glomerulitis (g2), peritubular capillaritis (ptc2), without interstitial inﬂammation or acute vascular injury (i0, t0, cg0, v0); C4d staining was positive, and there was no evidence of chronic interstitial injury (ct0, ci0, ah0, cv0), and anti-HLA antibody testing showed the presence of an A24 donor-speciﬁc antibody with mean ﬂuorescence intensity of 8200. The patient received plasmapheresis, intravenous immunoglobulins, and rituximab. Currently, the patient has no symptoms, the BP is 135/72 mm Hg, there no signs of congestion, and the allograft is nontender. Laboratory studies show sodium of 139 mEq/L, potassium of 4.7 mEq/L, BUN of 45 mg/dl, creatinine of 1.7 mg/dl (levels were 2.1 mg/dl 3 months ago)..
Question: The urinalysis shows speciﬁc gravity of 1.015, no glucose, and 1+ protein, no blood or ketones
Which ONE of the following would be the MOST appropriate to evaluate response to treatment in com-bination with creatinine and proteinuria?
1. Assess for donor-speciﬁc antibodies
2. Assess for tacrolimus trough level
3. Assess for mycophenolate mofetil area under curve
4. Assess for urinary chemokines
Answer: A