SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: End Stage Renal Disease & Dialysis
A 72-year-old woman with ESRD is found to have an elevated coronary calcium score on a study ordered by her primary care physician. She is concerned that her dialysate calcium level is set at 3.5 mEq/L. She asks whether her dialysate calcium should be reduced to 2.5 mEq/L. Her recent bone and mineral indices show calcium 8.7 mg/dl, phosphorus 5.6 mg/dl, and PTH 286 mg/dl..
Question: Which ONE of the following should you tell her has been shown to result from use of a dialysate calcium level of 2.5 mEq/L compared with 3.5 mEq/L over a period of 2 years?
A. A signiﬁcant reduction in mortality
B. No change in histologically evident low-turnover bone disease
C. A decrease in mean cancellous bone volume
D. A reduction in the progression of coronary artery calciﬁcation
Answer: D
Subject: End Stage Renal Disease & Dialysis
Question: Question 2775:
In the International Dialysis Outcomes and Practice Patterns Study (DOPPS), which ONE of the following factors has the STRONGEST association with increased interdialytic weight gains in ESRD patients treated with HD?
A. Higher dialysate sodium concentration
B. Lower normalized protein catabolic weight
C. Higher serum sodium concentration
D. Lower pre-HD systolic BP
Answer: A
Subject: End Stage Renal Disease & Dialysis
A 47-year-old woman has ESRD attributed to autosomal dominant polycystic kidney disease. She has received HD on a three-times-weekly schedule for the past 6 years. Her monthly laboratory tests show a calcium of 9.8 mg/dl, phosphorus of 4.9 mg/dl, and PTH of 524 pg/ml. She is concerned about the elevated PTH level. She tells you that she has been reading about bone disease in ESRD and is curious about the role of ﬁbroblast growth factor-23 (FGF23) in mediating abnormalities in her bone and mineral metabolism..
Question: Which ONE of the following should you tell her about FGF23?
A. Elevated FGF23 levels in ESRD consistently suppress serum PTH levels
B. FGF23 serum levels fall as serum PTH levels rise in ESRD
C. Elevated FGF23 serum levels in ESRD are associated with an increased risk of cardio-vascular events, infections, and mortality
D. Increased FGF23 levels in ESRD increase 1-α hydroxylation of 25-hydroxyvitamin D
Answer: C
Subject: End Stage Renal Disease & Dialysis
Your internal medicine colleague calls you because of her concerns about the deteriorating cognitive function in one of your patients. The patient is a 62-year-old woman with ESRD due to diabetic kidney disease. She initiated HD 1 year ago. Over the past 6 months she has had to retire from her position in an accounting ﬁrm because of poor job performance. Her spouse notes that she has been more withdrawn from social interactions and that she is no longer able to balance their checking account. Laboratory studies show adequate urea clearance and acceptable anemia and bone and mineral indices. A recent comprehensive neurologic evaluation showed no abnormalities except for evidence of small vessel disease on brain magnetic resonance imaging. Your colleague asks whether renal transplantation or a change in dialysis modality may offer beneﬁt..
Question: Which ONE of the following should you tell your colleague about cognitive function in ESRD patients?
A. The majority of patients on HD experience deterioration of cognitive function
B. Deterioration of cognitive function is not related to depression
C. At initiation of dialysis, cognitive performance is poor in comparison with patients in the general population, but it will always improve if a kidney transplantation is performed
D. The rate of decline in cognitive function within the ﬁrst 3 years of dialysis initiation is similar among patients treated with either PD or HD
Answer: A
Subject: End Stage Renal Disease & Dialysis
A 56-year-old man with a history of bilateral type 1 papillary renal cell carcinoma necessitating bilateral nephrectomy is seen 2 months after initiation of home HD. His tumors were localized and were completely resected. A living-related kidney transplantation is planned after a waiting period of 2 years. His hemoglobin has shown a progressive decrease from 12.3 g/dl to the current value of 7.4 g/dl despite optimization of his iron status with maintenance iron sucrose. He wants to avoid transfusions that may lead to allosensitization. However, after a discussion of beneﬁts and risks, he has opted to forego treatment with erythropoiesis-stimulating agents because of his recent cancer diagnosis even though he does not have active cancer. His medications include iron sucrose 50 mg once weekly and doxercalciferol 7 µg three times per week. Laboratory studies show a hemoglobin of 7.4 g/dl, transferrin saturation of 32%, ferritin of 450 ng/ml, albumin of 4.0 g/dl, calcium of 9.8 mg/dl, phosphorus of 4.9 mg/dl, and PTH of 286 pg/ml..
Question: Which ONE of the following is CORRECT regarding the treatment of his anemia?
A. There is no association of erythropoietin use and the de novo development of a malignancy
B. The iron sucrose at the prescribed dose should be discontinued because it increases the risk of infectious complications
C. Adding oral cinacalcet to reduce PTH levels will likely improve hemoglobin levels
D. Roxadustat is a possible future alternative agent for the treatment of his anemia
E. Competitive prolyl-hydroxylase inhibitors are ineffective in correcting anemia in patients who have undergone bilateral nephrectomy
Answer: D
Subject: End Stage Renal Disease & Dialysis
You are conducting a quality initiative project in your outpatient dialysis clinic with an oxygen saturation monitor. You discover that 10% of patients at your center have an oxygen saturation < 90% for more than one third of the recorded treatment time. You report the ﬁndings during a monthly quality assurance meeting of the clinic..
Question: Which ONE of the following should you indicate about the signiﬁcance of prolonged intradialytic hypoxemia (PIH) to your staff?
A. PIH is associated with higher all-cause hospitalization and mortality
B. On average, oxygen saturation is lowest in the last hour of treatment
C. Patients with PIH require lower doses of erythropoiesis-stimulating agents than do patients without PIH
D. PIH is more common in younger patients
Answer: A
Subject: End Stage Renal Disease & Dialysis
A 54-year-old physician with ESRD is evaluated during dialysis rounds. She complains of several weeks of increased pruritus but is otherwise asymptomatic. Her most recent laboratory studies show a corrected calcium of 9.8 mg/dl, serum phosphorus of 7.9 mg/dl, and a PTH of 730 pg/ml. She has been prescribed sevelamer carbonate 2400 mg three times daily with meals, but she takes it inconsistently because it causes nausea and diarrhea. Calcium acetate and lanthanum carbonate were not tolerated because of nausea. She asks about other alternatives. During this discussion, you explain to her that tenapanor, a novel agent that enhances gastrointesti-nal excretion of phosphate, is currently under investigation..
Question: Which ONE of the following should you tell her about tenapanor for the treatment of hyperphosphatemia in ESRD?
A. Tenapanor reduces serum phosphate con-centration by inhibiting the sodium-dependent phosphate transporter NPT2b located on the luminal membrane of the small intestine
B. Tenapanor treatment was associated with adverse events in < 5% of study participants, and the most common complaint in treated patients was nausea
C. Tenapanor caused a dose-dependent reduction in the serum phosphate concentration
D. Serum calcium levels decreased signiﬁcantly whereas the serum potassium concentrations remained unchanged
Answer: C
Subject: End Stage Renal Disease & Dialysis
A 67-year-old man with stage 5 CKD complicating chronic transplant rejection and obesity is seen for the onset of early uremic symptoms. He chooses PD and asks about the risk of developing peritonitis soon after having the catheter placed..
Question: Which ONE of the following should you tell him about early peritonitis?
A. Preoperative prophylactic antibiotics re-duce the risk of early peritonitis
B. Early peritonitis is less common in patients who have an embedded catheter placed
C. Patients who transition from a failed trans-plantation to PD are not at increased risk for early peritonitis
D. Patient weight has no bearing on the likelihood of the development of early peritonitis
Answer: A
Subject: End Stage Renal Disease & Dialysis
A 68-year-old woman with ESRD due to diabetic nephropathy and AF who has been maintained on PD for 3 years is evaluated 4 weeks after a recent hospitalization for peritonitis due to methicillin-resistant Staphylococcus species. Over the past 2 years, she has had four episodes of PD-related peritonitis. Since discharge, she has had increased leg edema and has had difﬁculty achieving adequate ultraﬁltration. Her medications include intraperitoneal vancomycin and warfarin. On physical examination, her abdomen is ﬁrm to palpation and diffusely tender. A peritoneal equilibrium test reveals a dialysate-to-creatinine ratio of 0.41, decreased from 0.63 six months ago. The peritoneal ﬂuid analysis reveals 10 total nucleated cells/mm3 with 40% neutrophils. A gram stain of the peritoneal efﬂuent is negative. A computed tomographic scan shows a thickened peritoneum, bowel wall thickening, and a few dilatated loops of bowel. A diagnosis of encapsulating peritoneal ﬁbrosis is made..
Question: Which ONE of the following placed this patient at increased risk for encapsulating peritoneal ﬁbrosis?
A. PD vintage for < 5 years
B. Absence of documented of high average peritoneal transport characteristics
C. Warfarin anticoagulation
D. Recurrent and recent bacterial peritonitis
Answer: D
Subject: End Stage Renal Disease & Dialysis
As Chair of the medical review committee for your ESRD network, you have been tasked with identifying best practices among centers in your region to improve outcomes in PD-related peritonitis..
Question: Which ONE of the following center characteristics is MOST likely to be associated with more favorable PD-related peritonitis outcomes?
A. Centers with <10 incident PD patients per year
B. Centers providing <10 hours of total training time
C. Centers with > 29% of dialysis patients treated with PD
D. Centers that train patients within the ﬁrst 10 days after catheter insertion
Answer: C
Subject: End Stage Renal Disease & Dialysis
A 45-year-old woman with stage 5 CKD is seen in consultation because of progressive azotemia and uremic symptoms after admission for management of anemia. Over the past four weeks, she has had worsening dysguesia, nausea, intermittent vomiting, and intermittent hiccups. On physical examination, her BP is 165/90 mmHg. She has mild pitting lower extremity edema and trace asterixis. Laboratory studies show a hemoglobin of 6.9 g/dl, potassium of 5.7 mEq/L, total CO2 of 15 mmol/L, BUN of 145 mg/dl, serum creatinine of 12 mg/dl, calcium of 8.4 mg/dl, and phosphorus of 7.8 mg/dl. You discuss renal replacement therapy and she understands that dialysis should be initiated now. She is disappointed that she failed to make adequate preparations for dialysis. She had originally hoped to undergo PD, but she had been told by another provider that the catheter requires at least 4 weeks to heal. She has not had prior abdominal surgery and has no obvious contraindications for PD. You begin a discussion about urgent-start PD..
Question: Which ONE of the following should you tell the patient about urgent-start PD?
A. Abdominal wall complications can be reduced to < 10% by initiating PD with low dwell volumes with gradual titration over the ﬁrst month of therapy
B. Pericatheter leak and subcutaneous leak are the most common mechanical complications of urgent-start PD
C. Urgent-start PD should always be initiated as intermittent peritoneal dialysis rather than automated peritoneal dialysis to avoid catheter dysfunction
D. Transfer to HD within 1 year occurs in over 30% of patients treated with urgent-start PD
Answer: A
Subject: End Stage Renal Disease & Dialysis
A 56-year-old man with stage 5 CKD due to hepatitis C–related membranoproliferative glomerulonephritis and cirrhosis is seen in consultation. His cirrhosis has been complicated by ascites and leg edema that have become increasing more difﬁcult to control with diuretics. He has not had encephalopathy or variceal bleeding. He is on the waiting list for a combined liver-kidney transplantation. His Child-Turcotte-Pugh class is B, and his Model for End-stage Liver Disease (MELD) score is 20. You conclude that he will likely require dialysis within the next 2 months, and you begin a discussion about dialysis options. He indicates a preference for PD..
Question: Which ONE of the following should you tell him about PD in the context of his cirrhosis?
A. Patients who have cirrhosis and ESRD who are treated with PD have a signiﬁcantly lower mortality in comparison with HD patients who have cirrhosis and ESRD.
B. Serum albumin is lower in patients with cirrhosis who undergo PD than in cirrhotic patients treated with HD
C. The MELD score is independently associated with all-cause mortality in patients with cirrhosis treated with PD
D. PD is contraindicated because he has ascites
Answer: A
Subject: End Stage Renal Disease & Dialysis
A 23-year-old man with type 1 diabetes mellitus maintained on home HD is evaluated during a monthly care conference. The ESRD developed because of diabetic nephropathy. A kidney trans-plant failed because of chronic rejection, and he began home HD 3 years ago. He had quit smoking before his transplantation, but he recently resumed smoking one pack of cigarettes per day. He occasionally smokes marijuana. He lives in an apartment two blocks away from the dialysis clinic. He has a well-matured arteriovenous ﬁstula (AVF), which has been in place for several years..
Question: Which ONE of the following factors is associated with an INCREASED risk of transition from home HD to in-center dialysis in this patient?
A. His age
B. Active smoking/substance abuse
C. History of kidney transplantation
D. Use of AVF compared with a central venous catheter
E. Residence proximate to his dialysis center
Answer: B
Subject: End Stage Renal Disease & Dialysis
Question: Question 2787:
Which ONE of the following statements is CORRECT regarding the mortality of patients with ESRD and disorders of glucose metabolism?
A. There is a U-shaped association between hemoglobin A1c levels and mortality
B. The lowest mortality among patients in the United States is associated with hemoglobin A1c levels in the 6% to 7% range
C. Following similar trends when compared with the general population, the life expectancy of women on dialysis with diabetes exceeds that of men on dialysis with diabetes
D. Glucagon-like peptide levels are not associated with mortality in patients with ESRD on long-term HD
Answer: A
Subject: End Stage Renal Disease & Dialysis
A 33-year old woman with ESRD due to diabetic kidney disease is evaluated during routine dialysis rounds. She is interested in trying pro-biotics to help her symptoms of intermittent loose stools. She has read about the role of gut bacteria in generating uremic toxins and asks about the impact of altering the gut microbiome..
Question: Which ONE of the following should you tell her about probiotics and alterations of the microbiome in patients on dialysis?
A. Oral vancomycin–induced suppression of gut bacteria is responsible for the degradation of tryptophan and tyrosine that leads to the accumulation of uremic byproducts in the serum of dialysis patients
B. Oral vancomycin increases the diversity of the gut microbiome in patients with ESRD receiving HD
C. Uremic toxins are thought to induce the enzyme transketolase in the human gut, causing functional thiamine deﬁciency
D. Diabetic ESRD patients who received pro-biotics containing lactobacillus were found to have decreased fasting serum glucose and serum insulin, along with increased insulin sensitivity
Answer: D
Subject: End Stage Renal Disease & Dialysis
A 55-year-woman with ESRD due to diabetes mellitus and obesity on maintenance HD is evaluated for exquisitely painful lesions that developed over the preceding 3 days on her thighs and lower abdomen. A skin biopsy demonstrates changes consistent with calciﬁc uremic arteriolopathy (CUA), or calciphylaxis. She is not on warfarin anticoagulation. She is subsequently enrolled in a study that requires baseline measurements of serum concentrations of matrix Gla protein (MGP)..
Question: Which ONE of the following is CORRECT with respect to her levels of MGP compared with ESRD patients without calciﬁc uremic arteriolopathy?
A. Her fraction of total MGP that is carboxylated is more likely to be lower
B. She is more likely to have reduced blood levels of uncarboxylated MGP
C. She is more likely to have reduced blood levels of carboxylated MGP
D. Her MGP levels are not associated with calciﬁc uremic arteriolopathy in the absence of warfarin therapy
Answer: A
Subject: End Stage Renal Disease & Dialysis
A 65-year-old man with stage 5 CKD is evaluated for increasing uremic symptoms. He has not yet started dialysis. He has sustained a 4-kg weight loss over a period of four weeks and has had dysguesia and anorexia over the past week. He has chosen in-center HD as his initial treatment modality. He has a well-matured AVF in place, which was created 18 months ago. You discuss starting dialysis electively, and the patient asks about incremental initiation of dialysis as opposed to a more traditional three-times-per-week schedule. His urea clearance is 10 ml/min per 1.73 m2..
Question: Which ONE of the following should you tell him about incremental initiation of dialysis and issues related to preservation of residual renal function?
A. Incremental HD is associated with a significantly slower decline in residual kidney function compared with conventional dialysis
B. Incremental HD is associated with in-creased mortality in patients with baseline residual urea clearance > 6ml/min per 1.73 m2
C. Preservation of residual renal function is associated with a mortality beneﬁt in PD but not HD
D. Patients who undergo incremental dialysis require lower doses of erythropoiesis-stimulating agents and have signiﬁcantly higher serum albumin levels
Answer: A
Subject: End Stage Renal Disease & Dialysis
A 64-year-old woman with ESRD on long-term HD with type 2 diabetes mellitus and AF is evaluated in follow up after a recent diagnosis of calciﬁc uremic arteriolopathy. Her medications are warfarin, sevelamer carbonate, sliding-scale insulin (currently receiving three to four injections per day), glipizide, and cinacalcet (60 mg daily). The physical examination shows tender necrotic lesions on her medial thighs without evidence of secondary infection. She is euvolemic. She has a functional left forearm AVF that does not have skin breakdown or aneurysmal dilatation. The remainder of the examination is normal. She is initially managed with an aggressive regimen of wound management, analgesics, and sodium thiosulfate. Warfarin is discontinued. Laboratory studies show sodium of 138 mEq/L, potassium of 3.8 mEq/L, chloride of 102 mEq/L, total CO2 of 24 mmol/L, calcium of 9.0 mg/dl, phosphorus of 4.3 mg/dl, PTH of 256 pg/ml, glucose of 158 mg/dl, and albumin of 3.8 g/dl. The single pool Kt/V is 1.5. The dialysate calcium concentration is 2 mEq/L..
Question: Which ONE of the following is the MOST appropriate next step in managing this patient’s CUA?
A. Avoid skin trauma and subcutaneous injections
B. Discontinue cinacalcet
C. Increase cinacalcet
D. Parathyroidectomy
E. Transfer to PD
Answer: A
Subject: End Stage Renal Disease & Dialysis
You see a 58-year-old African-American man with a history of ESRD attributed to diabetic nephropathy on HD with a newly hired advanced practice provider. The patient currently receives epoetin 16,000 units IV with each dialysis treatment and weekly sodium ferric gluconate 62.5 mg once per week. Laboratory studies show a hemoglobin of 11.4 g/dl, ferritin of 136 ng/dl, and transferrin saturation of 27%..
Question: The advanced practice provider asks about outcomes and the impact of using IV iron in combination with erythropoiesis-stimulating agents (ESAs) Which ONE of the following should you tell the advanced practice provider about the anemia-related and non–anemia-related effects of ESAs and iron therapy in patients undergoing HD?
A. Maintenance IV iron is not associated with a reduction in ESA use
B. Epidemiologic data suggest that the trend toward lower use of ESAs is associated with improved all-cause mortality in patients with ESRD
C. Maintenance IV iron is not associated with a greater likelihood of achieving hemoglobin levels between 10 and 12 g/dl
D. Administration of iron sucrose compared with ferrous gluconate in patients with ESRD is associated with increased infectious mortality
E. The modest association of cancer and ESA use is not dose dependent but rather is idiosyncratic
Answer: C
Subject: Primary Glomerular Disease
A 63-year-old white man is discovered to have trace to 1+ hematuria on dipstick urinalysis performed during a routine annual physical examination. This is conﬁrmed on a repeated urinalysis 2 weeks later. Test results for albuminuria were negative. An examination of the urine sediment revealed 5–10 erythrocytes per high power ﬁeld, 25%–30% of which were dysmorphic. No casts were observed. The urinalysis was normal 1 year ago. No urinary symptoms are present. There is no family history of hematuria. He takes no medication other than a low-dose aspirin daily. He is a lifelong cigarette smoker. The blood pressure and physical examination are normal except for a moderately enlarged, nontender prostate. The serum creatinine level is 0.9 mg/dl. Serum electrolytes, calcium, albumin, and total protein are all normal. A complete blood count is normal. The prostate-speciﬁc antigen level is 3 ng/ml. The urine albumin/creatinine ratio averaged 28 mg/g based on three measurements. A kidney ultrasound is normal..
Question: Which ONE of the following tests should be performed next?
A. Cystoscopy and computed tomographic urogram if the cystoscopy is normal
B. A 24-hour urine for albumin excretion
C. Serum C3, C4, and an anti–nuclear antibody
D. A serum free light chain assay
Answer: A
Subject: Primary Glomerular Disease
Question: Question 2794:
Which ONE of the following features noted in a kidney biopsy specimen should INCREASE suspicion of low nephron endowment in a non-obese child with a renal biopsy diagnosis of minimal change disease or FSGS?
A. Increased glomerular density (number of glomeruli per cubic millimeter)
B. Glomerular hypertrophy
C. Global glomerulosclerosis
D. Arteriolonephrosclerosis
Answer: B
Subject: Primary Glomerular Disease
A 22-year-old man develops sudden onset of nephrotic syndrome (serum albumin 1.9 g/dl and urine protein excretion 11 g per day) about a week after an upper respiratory infection. His past medical history includes onset of nephrotic syndrome at age 5 with a complete remission after steroid therapy. Infrequent relapses occurred at ages 7, 9, and 14, each fully responsive to an 8-week course of corticosteroids. A kidney biopsy performed at age 14 showed minimal change disease. A cousin has kidney disease of unknown cause. His physical examination shows marked peripheral edema. The blood pressure is 142/88 mmHg. The serum creatinine level is now 1.1 mg/ dl. A urinalysis shows a trace of blood and 4+ protein. The serum C3 level is normal..
Question: Which ONE of the following is the MOST appropriate next step in management?
A. Perform genetic studies for a podocytopathy
B. Start empiric therapy with cyclosporine
C. Repeat kidney biopsy
D. Start empiric therapy with oral corticosteroids
Answer: D