SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Acute Kidney Injury & Critical Care Nephrology

You are asked to comment on the risk of peri-operative AKI in a 70-year-old black man who is scheduled for nontraumatic hip arthroplasty. He has stage G3b:A1 CKD, diabetes mellitus, and well compensated congestive heart failure. He does not have chest pain on exertion, short-ness of breath, or orthopnea. On physical examination, the BP is 132/82 mmHg, and the heart rate is 62/min. The jugular venous pressure is < 5cm H2O. The lungs are clear. The cardiac examination shows an S4 gallop. There is no edema. The remainder of the examination is normal. Laboratory studies show creatinine of 1.8 mg/dl (stable) and an eGFR of 43ml/min per 1.73m2..
Question: Which ONE of the following is the STRONGEST predictor of AKI in nontraumatic hip arthroplasty in this man?
1. Black race
2. Diabetes mellitus
3. History of congestive heart failure
4. Baseline CKD
Answer: D
Subject: Acute Kidney Injury & Critical Care Nephrology

A 65-year-old man with stage G3a:A1 CKD, type 2 diabetes mellitus, and chronic obstructive pulmonary disease is seen for acute bronchitis and hypertension. Review of his home BPs over the past 2 months shows an average BP of 156/94 mmHg. His medications are irbesartan 300 mg daily, chlorthalidone 25 g daily, pravastatin 40 mg daily, and metformin 500 mg twice daily. On physical examination, he is not in acute respiratory distress. The BP is 160/90 mmHg. The lung examination shows diffuse rhonchi. There is no edema. The remainder of the examination is normal. Laboratory studies show a stable serum creatinine of 1.4 mg/dl (eGFR 51 ml/min per 1.73 m2). You decide to add a dihydropyridine calcium blocker to address the hypertension and a macrolide antibiotic to treat the pulmonary infection..
Question: Prescription of which ONE of the following medication combinations is associated with the GREATEST risk for hospitalization with AKI over the next month?
1. Amlodipine and azithromycin
2. Amlodipine and clarithromycin
3. Nifedipine and azithromycin
4. Nifedipine and clarithromycin
Answer: D
Subject: Acute Kidney Injury & Critical Care Nephrology

A 70-year-old woman who is kidney transplant recipient is admitted for management of urosepsis. She is initially treated with ceftriaxone but continues to have recurrent high fevers 1 day after admission. On physical examination, she appears toxic. The temperature is 39.2 C, the BP is 110/78 mmHg, and the heart rate is 100/min. There is minimal allograft tenderness. The remainder of the examination is normal. Laboratory studies show that the serum creatinine is 1.2 mg/dl and unchanged from her baseline level. A urinalysis shows large leukocyte esterase and 100 leukocytes per high-power ﬁeld. No bacteria are seen. Blood and urine cultures show no growth so far. You recommend addition of vancomycin..
Question: Her internist raises concerns about potential nephrotoxicity.
1. Vancomycin-associated AKI only occurs when co-administered with piperacillin-tazobactam
2. The risk of AKI is not increased unless vancomycin levels exceed the therapeutic range for > 3 days
3. She is not at risk for vancomycin-associated AKI, because her baseline renal function is normal
4. Her risk of AKI is twofold higher than if she were not treated with vancomycin
Answer: D
Subject: Acute Kidney Injury & Critical Care Nephrology

A 34-year-old combat victim is ﬂown to a military hospital after sustaining multiple gunshot wounds to the head, chest, and abdomen..
Question: Which ONE of the following places this trauma victim at increased risk for rhabdomyolysis?
1. Chest injury
2. Head injury
3. Abdominal injury
4. Gunshot versus explosive mechanism injury
Answer: C
Subject: Acute Kidney Injury & Critical Care Nephrology

A 77-year-old man with stage G3a CKD is evaluated in the ofﬁce after being diagnosed with Helicobacter pylori several days ago. He has hypertension, type 2 diabetes mellitus, and coronary heart disease. Medications are metformin, carvedilol, lisinopril, chlorthalidone, and pravastatin. His gastroenterologist has recommended treatment with clarithromycin, amoxicillin, and esomeprazole..
Question: Which ONE of his medications should not be coprescribed with clarithromycin to avoid an increased risk of AKI?
1. Lisinopril
2. Pravastatin
3. Carvedilol
4. Metformin
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology

A 76-year-old man is admitted for management of acute decompensated heart failure. Furosemide is administered by continuous infusion at a dose of 10 mg/h. In addition, he is continued on his home regimen of lisinopril and metoprolol. On day 3 of treatment, he has achieved a net negative output of 12 L, but his BUN and creatinine have risen from20 mg/dl and1.4 mg/dlto65mg/dl and 3.0 mg/dl, respectively..
Question: Which ONE of the following statements BEST describes his renal status?
1. Stage 1 AKI
2. Stage 2 AKI
3. Stage 3 AKI
4. Type 5 cardiorenal syndrome
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology

A 60-year-old man is admitted to the neurosurgical ICU after falling and sustaining a traumatic subdural hematoma. He is evaluated with two contrasted computed tomography scans over the ﬁrst 24 hours of admission. On hospital day 3, the urine output decreases to 0.25 ml/kg per hour. He is undergoing continuous monitoring of his intracranial pressure, which remains under tenuous control. Laboratory studies show sodium 135 mEq/L, potassium 6.5 mEq/L, chloride 101 mEq/L, total CO2 19 mmol/L, BUN 53 mg/dl, and creatinine 2.8 mg/dl (increased from 1.4 mg/dl on admission). A urinalysis shows three to ﬁve muddy brown casts per high-power ﬁeld. The fractional excretion of sodium is 0.9%. You recommend initiation of renal replacement therapy..
Question: Which ONE of the following is the BEST choice of renal replacement therapy for this man on the basis of the most recent Kidney Disease Improving Global Outcomes guidelines?
1. Intermittent hemodialysis (4 hours 3 d/week)
2. Continuous RRT (24 h/day)
3. Intermittent hemodiaﬁltration (4 hours 3 d/week)
4. Prolonged intermittent RRT (8 h/day)
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology

A 47-year-old woman with advanced heart failure awaiting heart transplantation is seen in consultation for persistent kidney dysfunction. Her cardiologist has recommended placement of a ventricular assist device (VAD) before transplant because of refractory heart failure despite optimal pharmacologic and device treatment. Her eGFR has been stable at 30 ml/min per 1.73 m2 over the past 2 weeks. She asks about the effect of VAD placement on her renal prognosis..
Question: Which ONE of the following would you advise regarding the expected renal outcomes of VAD placement?
1. She is likely to experience at least a transient improvement in kidney function
2. If her eGFR increases to > 60 ml/min per 1.73 m2, her 1-year survival following transplant is likely to be worse than that in those with normal pre-VAD eGFR
3. Her risk of post-VAD AKI is equivalent to that in those with normal pre-VAD kidney function
4. She can expect a sustained increase in eGFR of > 50 ml/min per 1.73 m2 above the pre-VAD eGFR at 1 year while awaiting transplant
Answer: A
Subject: Acute Kidney Injury & Critical Care Nephrology
Question: Question 5468
Which ONE of the following statements BEST characterizes the relationship between AKI and long-term risk of CKD?
1. The risk of CKD after AKI is similar across individuals with varying levels of baseline kidney function
2. Advanced CKD prior to AKI attenuates the effect of AKI on the long-term risk of progressive CKD
3. The level of CKD prior to AKI has no prognostic effect on post-AKI risk of CKD
4. The severity of AKI and not the level of baseline CKD is the major determinant of long-term risk of CKD
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology

A 52-year-old man with recently diagnosed cirrhosis secondary to hepatitis C is evaluated in 1 week following a hospitalization for increased ascites, spontaneous bacterial peritonitis, and transient AKI. The SCr rose to 2.3 mg/dl but is now 1.1 mg/dl. His medications are spironolactone, furosemide, ranitidine, and lactulose. On physical examination, the BP is 112/76 mmHg, and the heart rate is 76/min. The abdomen is soft with minimal ascites. There is no leg edema..
Question: Addition of which ONE of the following would you recommend to decrease this man’s long-term risk of AKI and hepatorenal syndrome?
1. Norﬂoxacin or rifaximin
2. Carvedilol
3. Pentoxifylline
4. Midodrine
Answer: A
Subject: Acute Kidney Injury & Critical Care Nephrology

A 52-year-old man with metastatic melanoma, gout, and gastroesophageal reﬂux disease is seen in consultation for AKI complicating nivolumab therapy. He has had mild diarrhea but has been eating and drinking without difﬁculty. His medications include allopurinol and omeprazole. On physical examination, his BP is 136/92 mmHg, and the heart rate is 85/min without postural changes. There is no rash. The remainder of the examination is normal. Laboratory studies show sodium 138 mEq/L, potassium 5.2 mEq/L, chloride 107 mEq/L, total CO2 20 mmol/L, BUN 32 mg/dl, and creatinine 1.9 mg/dl (increased from 0.9 mg/dl 1 week ago). The leukocyte count is 4900/µl, the hemoglobin is 12.2 g/dl, and the platelet count is 247,000/µl. A kidney ultrasound shows normal-sized kidneys and no hydronephrosis. A urinalysis shows trace protein, 15–20 leukocytes per high-power ﬁeld, and occasional leukocyte casts..
Question: In addition to holding nivolumab, which ONE of the following is the MOST appropriate initial treatment?
1. No further treatment
2. Prednisone 0.5–1 mg/kg per day
3. Plasma exchange
4. Rituximab
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology

An 80-year-old man is hospitalized for AKI. His family noted onset of increased confusion 2 days ago. He had been eating and drinking without difﬁculty until 1 day before admission. His medications are allopurinol, pantoprazole, amlodipine, and atorvastatin. On physical examination, he is somnolent, and oriented only to self. The BP is 160/94 mmHg, and the heart rate is 65/min. The jugular venous pressure is increased to 8 cm H2O. Examination of the chest shows bibasilar crackles. There is moderate tenderness in the suprapubic region, but there are no peritoneal signs. There is 2+ pretibial edema. The remainder of the examination is unremarkable. Laboratory studies show sodium 137 mEq/L, potassium 5.8 mEq/L, chloride 109 mEq/L, total CO2 16 mmol/L, BUN 28 mg/dl, and creatinine 1.6 mg/dl (increased from a recent baseline value of 0.7 mg/dl). The leukocyte count is 7800/µl, the hemoglobin is 11.9 g/dl, and the platelet count is 289,000/µl. A urinalysis shows trace protein, negative blood, one to three monomorphic erythrocytes per high-power ﬁeld, and three to ﬁve leukocytes per high-power ﬁeld..
Question: Which ONE of the following diagnostic tests is MOST likely to inﬂuence management in this man?
1. Serum creatine kinase
2. Urine eosinophils
3. Kidney ultrasound
4. Serum antineutrophil cytoplasmic antibody
Answer: C
Subject: Acute Kidney Injury & Critical Care Nephrology

A 20-year-old man is seen in consultation for AKI. Over the past 4 days, he has been smoking illicit “cigarettes” that he purchased at a party. He subsequently developed intermittent nausea, vomit-ing, and bilateral ﬂank pain. On physical examination, the BP is 132/80 mmHg, and the heart rate is 82/min. The remainder of the examination is normal. Laboratory studies show sodium 142 mEq/L, potassium 5.4 mEq/L, chloride 110 mEq/L, total CO2 19 mmol/L, BUN 38 mg/dl, creatinine 3.7 mg/dl, calcium 9.2 mg/dl, magnesium 1.8 mg/dl, phosphorus 4.8 mg/dl, creatine kinase 156 U/L (reference range 570–185 U/L), leukocyte count 7900/µl, hemoglobin 13.3 g/dl, and platelets 289,000/µl. The fractional excretion of sodium is 6%. A urinalysis shows 1+ protein, negative blood, four to six renal tubular epithelial cells per high-power ﬁeld, and occasional muddy brown casts. No crystals are seen. A kidney ultrasound shows normal-sized kidneys with increased echogenicity..
Question: Which ONE of the following is the MOST likely cause of his AKI?
1. Synthetic cannabinoids
2. Heroin
3. Levamisole-adulterated cocaine
4. Crystal methamphetamine
Answer: A
Subject: Acute Kidney Injury & Critical Care Nephrology

A 56-year-old woman with IgA lambda multiple myeloma undergoing treatment with cyclophosphamide, carﬁlzomib, and dexamethasone is seen in consultation for AKI. One year ago, she received an autologous stem cell transplant after treatment with melphalan. She was subsequently maintained on bortezomib and lenalidomide but transitioned to cyclophosphamide, carﬁlzomib, and dexamethasone 2 weeks ago after she was found to have a relapse of myeloma. Over the past 10 days, she noted onset of fatigue, nausea, anorexia, and dyspnea on exertion. On physical examination, there is pallor. The BP is 146/85 mmHg, and the heart rate is 98/min. Examination of the skin shows scattered ecchymoses and petechiae. The remainder of the examination is normal. Laboratory studies show sodium 136 mEq/L, potassium 5.7 mEq/L, chloride 108 mEq/L, total CO2 18 mmol/L, BUN 48 mg/dl, creatinine 2.6 mg/dl, calcium 8.6 mg/dl, albumin 3.8 g/dl, phosphorus 5.2 mg/dl, and lactate dehydrogenase 356 U/L (reference range 560–100 U/L). A peripheral blood smear shows 4% schistocytes. A direct Coombs antiglobulin test is neg-ative. A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 activity is 82%. Urinalysis shows trace protein and blood. Microscopic examination of the urinary sediment shows three to eight erythrocytes per high-power ﬁeld with occasional acanthocytes..
Question: Which ONE of the following therapeutic agents is MOST likely responsible for AKI in this woman?
1. Carﬁlzomib
2. Lenalidomide
3. Melphalan
4. Cyclophosphamide
Answer: A
Subject: Interventional Nephrology & Dialysis Therapy
In 2016, eligibility criteria for simultaneous liver-kidney transplant were developed and approved by the Organ Procurement and Transplantation Network..
Question: Which ONE of the following liver transplant candidates is NOT eligible for simultaneous liver-kidney transplantation?
A. A 64-year-old man with stage 3 CKD (eGFR of 54.5–50 ml/min per 1.73 m2) documented for 4 months and a recent fall in eGFR during a period of hypovolemia to 25 ml/min per 1.73 m2
B. A 19-year-old woman with primary hyper-oxaluria, nephrocalcinosis, and stage 5 CKD
C. A 54-year-old man with HCV infection, type 2 diabetes mellitus, an eGFR of 35–40 ml/min per 1.73 m2, and proteinuria of 1 g/d
D. A patient with type 2 hepatorenal syndrome with an eGFR of 15–25 ml/min per 1.73 m2 over the past 6 weeks
Answer: C
Subject: Interventional Nephrology & Dialysis Therapy
Practice patterns regarding vascular access modalities at the time of hemodialysis (HD) initiation have changed in the United States between 2005 and 2014..
Question: Which ONE of the following BEST depicts the changes in incident vascular access during this interval (2005–2014)?
A. An increase in incident ﬁstula rate, graft rate, and catheter rate
B. No change in incident ﬁstula rate, graft rate, and catheter rate
C. An increase in incident ﬁstula rate and a decline in graft and catheter rate
D. An increase in incident ﬁstula rate, a decline in graft rate, and no change in catheter rate
E. A decrease in incident ﬁstula rate, a decline in graft rate, and an increase in catheter rate
Answer: D
Subject: Interventional Nephrology & Dialysis Therapy
A 61-year old man with ESRD due to diabetic kidney disease began maintenance HD 5 months ago. He is currently receiving dialysis through a tunneled right internal jugular catheter. He has a maturing arteriovenous ﬁstula that was placed 6 weeks ago. The leukocyte count is 10,000/µL, the hemoglobin level is 9.2 g/dL, the Kt/V is 1.2, and the serum albumin level is 2.9 g/dL..
Question: After successful transition to dialysis access through the arteriovenous ﬁstula, which ONE of the following outcomes is MOST likely to occur?
A. A decrease in the hemoglobin level
B. An increase in the leukocyte count
C. An improvement in serum albumin
D. An increase in erythropoietin requirement
E. A decreased likelihood of survival over the next year
Answer: C
Subject: Interventional Nephrology & Dialysis Therapy
A 55-year-old woman is seen in the clinic for follow-up of stage 4 CKD. Her estimated GFR is 18 ml/min per 1.73 m2. Creation of an arterio-venous ﬁstula is scheduled for next week..
Question: Which ONE of the following factors is MOST likely to predict failure of arteriovenous maturation in this patient?
A. Preexisting neointimal hyperplasia in the ﬁstula vein biopsy specimen taken at the time of surgery
B. Failure to perform preoperative vessel mapping
C. Predialysis care < 12 months
D. Fistula creation by a surgeon who has created > 25 ﬁstulas during surgical training
E. The fact that she is female
Answer: E
Subject: Interventional Nephrology & Dialysis Therapy
A 71-year-old man with ESRD due to diabetic nephropathy who has just started HD with a catheter is seen during weekly dialysis rounds. A discussion begins about the relative beneﬁts and risks of an arteriovenous ﬁstula versus an arteriovenous graft..
Question: Which ONE of the following should you tell him about the different types of arteriovenous access?
A. His survival with a catheter is likely to be similar to that achieved with a ﬁstula or a graft
B. The catheter dependence period is likely to be higher during the ﬁrst 6 months with a graft than with a ﬁstula
C. Infection-related hospitalization is more likely with ﬁstulas
D. Septicemia-related or bacteremia-related hospitalization is more likely with ﬁstulas
E. The risk of death is lower with ﬁstulas than with grafts
Answer: E
Subject: Interventional Nephrology & Dialysis Therapy
A 63-year-old man who has received maintenance HD through central venous catheters for the past 6 months is evaluated during HD rounds. His course has been complicated by recurrent episodes of bacteremia and catheter dysfunction that began 2 weeks after the ﬁrst catheter was placed. Previous attempts at arteriovenous ﬁstula creation failed because of nonmaturation. Vascular ultrasonography shows patent central veins and an absence of peripheral veins suitable for ﬁstula creation..
Question: Which ONE of the following strategies is MOST likely to provide the quickest transition away from catheter-based HD?
A. Placement of a hybrid graft–catheter device
B. Placement of a graft with a venous stent
C. Placement of an early cannulation arterio-venous graft
D. Placement of an arteriovenous ﬁstula with sirolimus wrap around an arterial anastomosis
Answer: C
Subject: Interventional Nephrology & Dialysis Therapy
A 35-year-old woman with ESRD due to focal and segmental glomerulosclerosis, who is receiving maintenance in-center HD through a right forearm arteriovenous ﬁstula, is evaluated during routine HD rounds. Over the past 3 months she has required hospitalization on three occasions for acute decompensated heart fail-ure. She has persistent dyspnea after walking less than one block, and her symptoms only partially improve after each dialysis session. Attempts to lower her dry weight have been unsuccessful because of intradialytic hypotension even after her dialysis time is prolonged to 5 hours. Her interdialytic weight gains average 2 kilograms. On physical examination, her blood pressure is 108/70 mmHg, and her heart rate is 102/min. Her right arm arteriovenous ﬁstula is serpiginous, tortuous, and widely dilatated with areas of aneurysmal dilatation. Her jugular venous pressure is 10 cm H2O. Hepatojugular reﬂux is present. Her cardiac apex is hyper-dynamic. She has modest ascites and trace pretibial edema. Her hemoglobin is 10.7 g/dl, thyroid stimulating hormone is 2 IU/L (reference range 0.6–3.3 IU/L), and free T3 and T4 are normal. A recent echocardiogram shows no signiﬁcant valvular abnormalities, a small pericardial effusion, normal left ventricular size, mild concentric hypertrophy, normal systolic function, and grade 2 left ventricular diastolic dysfunction..
Question: Which ONE of the following is the MOST appropriate next step in evaluation and management?
A. Adjustment of erythropoiesis-stimulating therapy, targeting a hemoglobin of 12 g/dl
B. Placement of a tunneled catheter for dialysis and ligation of arteriovenous ﬁstula
C. Measurement of access ﬂow and cardiac output
D. Aggressive paracentesis
Answer: C
Subject: Interventional Nephrology & Dialysis Therapy
A 39-year-old man has ESRD due to recurrent AKI consequent to cocaine abuse and has required dialysis with tunneled catheters in the past. He has received dialysis through a left forearm arteriovenous graft for the past 6 months. He is found to have a clotted dialysis access when he presents for his scheduled HD treatment. He is in no respiratory distress, and his weight is 2 kilograms above his estimated dry weight. Examination of his left arm reveals no aneurysms or evidence of infection. He does not have facial or arm edema. During endovascular thrombectomy, a 90 percent stenosis of the venous anastomosis is noted. He undergoes successful declotting of the access with angioplasty of the stenosis followed by a stent placement. Central venography shows a 50 per-cent stenosis of the brachiocephalic vein..
Question: Which ONE of the following represents the MOST appropriate next step in management?
A. Angioplasty of the brachiocephalic vein stenosis without stent placement
B. Angioplasty of the brachiocephalic vein stenosis plus a bare metal stent placement
C. Angioplasty of the brachiocephalic vein stenosis plus placement of a stent graft
D. Placement of a hybrid graft catheter device for central vein stenosis
E. No additional intervention
Answer: E
Subject: Interventional Nephrology & Dialysis Therapy
A 54-year-old kidney transplant recipient has progressive allograft dysfunction and is expected to require dialysis in 4 to 6 weeks. She is now ready to begin preparing for dialysis and is considering all options. She does not have uremic symptoms. She has no contraindications to peritoneal dialysis (PD). The physical examination is remarkable only for modest pedal edema. Laboratory studies show hemoglobin of 10.5 g/dl, potassium of 4.3 meq/L, total CO2 of 23 mmol/L, and serum creatinine level of 4.2 mg/dl. A left forearm brachiocephalic arteriovenous graft has not functioned for over 19 years. Vein mapping shows a patent left upper arm outﬂow cephalic vein from a previous arteriovenous graft. The veins in her right upper extremity are also suitable for placement of an arteriovenous ﬁstula..
Question: Which ONE of the following is the LEAST appropriate strategy to initiate dialysis in this patient?
A. Placement of a secondary ﬁstula using the out-ﬂow vein of the previous arteriovenous graft
B. Placement of a tunneled central vein catheter closer to the initiation of dialysis
C. Placement of a right forearm arteriovenous ﬁstula
D. Placement of a PD catheter to start PD
E. Placement of an arteriovenous graft closer to the initiation of dialysis
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
A 38-year-old man with type 1 diabetes has progressive CKD and is anticipated to require dialysis in about 3 months. After considering his modality options, he indicates a preference for HD. He has recurrent osteomyelitis of the right foot and has been hospitalized four times over the past 6 months for debridement and intravenous antibiotics. He has required placement of multiple peripheral and central intravenous catheters. His most recent laboratory studies show an estimated GFR of 16 ml/min per 1.73 m2..
Question: Which ONE of the following is the BEST preoperative imaging study to plan this patient’s access surgery?
A. Vascular ultrasonographic mapping of peripheral and central veins
B. Small-dose venography to assess peripheral and central veins
C. Selective vasculature ultrasonographic mapping of the peripheral veins only if no suitable veins are identiﬁed on physical examination
Answer: B