SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Transplantation

A 22-year-old woman with stage 4 CKD secondary to IgA nephropathy with a current eGFR of 17 ml/min per 1.73 m2 comes to clinic for follow-up. She has a history of hypertension, and her BMI is 37 kg/m2. She is interested in renal transplantation but currently has no potential live kidney donors. You have previously dis-cussed bariatric surgery with her, but she is cautious about considering this. As you discuss options for renal replacement therapy, she asks about the transplantation evaluation process and what factors might affect her ability to get a kidney..
Question: With regard to access to renal transplantation, which ONE of the following is correct?
1. Receiving dialysis at a for-proﬁt dialysis unit is associated with lower rates of renal transplantation referral
2. In an analysis by the Southeast Kidney Consortium, Black and non-Hispanic patients had similar rates of initiation of transplantation evaluation after transplantation referral as other groups
3. Prior bariatric surgery is a contraindication to renal transplantation
4. Since the introduction of the kidney allocation system in 2014, patients with the highest estimated post-transplantation survival (EPTS score) receive priority access to all kidneys for transplantation
Answer: A
Subject: Transplantation

A 62-year-old man with stage 4 CKD, eGFR 16 ml/min per 1.73 m2, comes to clinic for routine follow-up. After reviewing his symptoms, physical examination results, and medications, you discuss referral for transplantation evaluation with him. You explain that because his eGFR is currently < 20 ml/min per 1.73 m2, he can be pre-emptively listed for renal transplantation and begin to accumulate wait time. He asks about deceased versus live kidney donation and expresses reservations about asking a family member to donate..
Question: Which ONE of the following is correct regarding access to live donor renal transplantation?
1. Educational and support programs targeted at minority transplantation candidates and their families can increase the chance of receiving a live donor kidney
2. Recipients of a prior kidney transplant have increasing rates of pre-emptive listing of retransplantation in recent years
3. Removing the Black race coefﬁcient from GFR estimating equations has been predicted to decrease the time to reach an eGFR of < 20 ml/min per 1.73 m2 by around 6 to 9 months
4. The majority of disparities in transplantation listing seen between White and Black candidates is explained by differences in levels of comorbidity and medical barriers to transplantation
Answer: A
Subject: Transplantation

A 43-year-old female with ESKD secondary to IgA nephropathy has been on the renal transplant wait list for 6 years. She receives an offer of a deceased donor kidney. The 62-year-old donor died due to a motor vehicle accident and had a history of smoking and well-controlled hypertension. Donor testing is positive for anti-HCV antibody, but HCV nucleic acid testing (NAT) is negative. A renal biopsy is acquired at the time of organ harvest..
Question: Which ONE of the following is correct with regard to predicting outcome of deceased donor kidneys?
1. The presence of macroscopic arteriosclerosis on pre-transplantation biopsy predicts poorer allograft outcomes
2. The histological features on pre-transplantation biopsy are more strongly predictive of graft loss than the presence of donor-speciﬁc antibodies
3. Donor HCV antibody positive status is associated with higher rates of kidney discard
4. In an analysis comparing kidneys discarded in the US due to histological features with matched kidneys transplanted in France, the allograft survival rate was 80% at 5 years
Answer: D
Subject: Transplantation

A 55-year-old woman underwent a deceased donor kidney transplantation 1 year ago. At 4 months after trans-plantation, she had a grade IB acute cellular rejection that was treated with corticosteroids. Currently her allograft function is stable, with a creatinine of 1.4 mg/dl, and she has no proteinuria, but new donor-speciﬁc antibody is present. A surveillance kidney biopsy was performed, and the biopsy sample showed ﬁbrosis of 20% of the cortex. She has interstitial inﬂammation involving > 25% of the sclerotic parenchyma and > 25% of the total cortical parenchyma with moderate tubulitis..
Question: Based on the current Banff classiﬁcation, how should her rejection be classiﬁed?
1. Grade IA active T cell–mediated rejection
2. Chronic active antibody-mediated rejection
3. Grade 1A chronic active T cell-mediated rejection
4. No rejection because there is inﬂammation in areas of scarred cortex
Answer: C
Subject: Transplantation

A 62-year-old man with a history of a living related donor kidney transplantation 4 months ago was seen for routine follow-up. His creatinine was elevated to 2.2 mg/dl, which was up from a baseline of 1.4 mg/dl. He had no donor-speciﬁc antibody identiﬁed, and the result of testing for BK viremia was negative. His indication biopsy showed a Banff IIA acute cellular rejection. He was treated with corticosteroids with improvement of his creatinine back down to baseline, and examination of a follow-up biopsy specimen showed resolution of inﬂammation in nonﬁbrotic cortex..
Question: Which of the following statements is TRUE based on long-term follow-up studies?
1. The patient is at increased risk for death with a functioning graft
2. Studies of surveillance biopsies performed on transplants have shown that allograft failure is most commonly due to alloimmune injury
3. Given that the biopsy specimen showed resolution of inﬂammation, this rejection will likely have no effect on his allograft function in the long term
4. The patient is likely to eventually experience chronic antibody-mediated rejection
Answer: A
Subject: Transplantation

A 23-year-old man is listed for a kidney transplantation and fortunately has an unrelated potential living donor who is a 4/6 HLA mismatch and matched at the DR locus. He has questions about kidney paired donation and the role of DR/DQ eplet matching..
Question: Which of the following statements is MOST CORRECT with regard to how you should counsel the patient?
1. There is no role for eplet matching because he is matched at the DR locus
2. It would be helpful to ﬁrst look at the matching at the DQ locus; if he is not matched at DQ, eplet matching may be of beneﬁt
3. He should consider eplet matching because he is mismatched at the A locus
4. Eplet matching may not have a role when there is a living kidney donor available
Answer: B
Subject: Transplantation

Your patient is a 45-year-old woman with two prior failed transplants. She underwent a positive crossmatch kidney transplantation 2 years ago and has an increase in creatinine. Her biopsy shows a chronic active antibody-mediated rejection with microvascular inﬂammation (peritubular capillaritis and glomerulitis) and mild transplant glomerulopathy. No acute T cell–mediated rejection is present. She is interested in learning more about clinical trials with IL-6 antagonists..
Question: Which of the statements is INCORRECT regarding what is known about the use of IL-6 inhibitors for treatment of rejection?
1. Patients were withdrawn from the initial pilot study with clazakizumab because of complications from diverticular disease
2. IL-6 inhibitors have been shown to improve long-term allograft survival in randomized controlled trials
3. Preliminary studies have shown that IL-6 inhibitors are associated with stabilization of eGFR
4. IL- 6 receptor antagonists are associated with increased systemic IL-6, which can lead to rapid deterioration of allograft function after they are stopped
Answer: B
Subject: Transplantation

A 55-year-old woman with ESKD from autosomal dominant polycystic kidney disease returns to clinic for continued care after a living unrelated kidney transplant from her husband 6 months ago. She has gained 30 pounds and has had more difﬁculty sleeping, and walking up tired and “groggy.” She is adherent to her maintenance immunosuppression regimen of tacrolimus 2 mg twice a day, mycophenolate mofetil 1000 mg twice a day, and prednisone 5 mg daily. She is also taking atorvastatin 10 mg daily, amlodipine 5 mg daily, and metoprolol 50 mg twice a day. Her in-ofﬁce BP is 165/90 mm Hg, and repeated BP 15 minutes later is 155/85 mm Hg. Her physical examination results are signiﬁcant for a protuberant abdomen, palpable kidneys, a well-healed incision in the right lower quadrant, and trace lower extremity edema bilaterally. Creatinine is 1.1 mg/dl, electrolytes are normal, fasting blood glucose level is 98 mg/dl, tacrolimus level is 7, and urine analysis shows trace of blood but no red blood cells, speciﬁc gravity of 1.002, negative protein, glucose, and infection..
Question: Based on this presentation, which of the following factors is MOST likely to affect this patient’s long-term survival?
1. Polycystic native kidneys with malignant transformation to renal cell carcinoma
2. Uncontrolled hypertension with concern for pulmonary hypertension
3. Allograft rejection due to subtherapeutic tacrolimus
4. Development of post-transplantation diabetes mellitus, given her 30 pounds of weight gain
Answer: B
Subject: Transplantation

A 35-year-old man with FSGS who received a living related kidney transplant from his father 15 years ago returns to clinic for his annual visit. His post-transplantation course was complicated by antibody-mediated rejection 5 years ago when he lost his job and immuno-suppression coverage lapsed. He was told 6 months ago by his transplantation nephrologist that his kidney function is declining. He does not describe uremic symptoms and is continuing to work full time as a custodian. His serum creatinine has been 3.8 to 4.2 mg/dl (eGFR 18–20 ml/min). The result of panel reactive antibodies is 50%class I and 30% class II. A renal biopsy shows 80% interstitial ﬁbrosis and tubular atrophy and chronic antibody-mediated injury. His current immunosuppression is cyclosporine 100 mg twice a day, azathioprine 100 mg daily, and prednisone 5 mg daily, but he admits to missing his medications a few times during the week because of his work schedule. His girlfriend, who has accompanied him to clinic, asks about the possibility of being a living donor..
Question: Which of the following is the MOST appropriate counseling?
1. Patient does not require a second transplant at this time, given the absence of uremic symptoms, and medical management should now focus on extending the longevity of the current transplant
2. Patient does require a second transplant but can-not be listed until his eGFR is < 15 ml/min or he requires dialysis
3. Patient does require a second transplant and can be listed but should be weaned off some immuno-suppression and have a short course of dialysis to prove his adherence to medical therapy
4. Patient will require a second transplant and should be listed and maintained on current immunosuppression while his potential living donor is evaluated
Answer: D
Subject: Transplantation

A nephrology consultation is requested a patient admitted with AKI. He is a72-year-oldmanwithkidney transplantation 5 years ago complicated by metastatic melanoma and was started 3 weeks ago on programmed cell death ligand-1 (anti-PD-1) therapy with nivolumab. He has experienced abdominal pain and diarrhea and reports a ﬂare of his psoriasis. On physical examination he is normotensive and has no evidence of orthostatic hypotension..
Question: Of the following statements regarding immune check-point inhibitors, which ONE is NOT TRUE?
1. Checkpoint inhibitors are associated with immune-related manifestations of colitis, thyroiditis, and rash
2. His allograft dysfunction is most likely related to volume depletion and prerenal AKI
3. A renal biopsy will not distinguish acute interstitial nephritis caused by anti-PD-1 agent from transplant rejection
4. Acute rejection rates are roughly 40% to 50% and occur within 3 weeks of treatment initiation
Answer: B
Subject: Transplantation

A 32-year-old woman is being evaluated at your trans-plantation program for being a living kidney donor to her father, who has ESKD presumed secondary to hypertension. She has no signiﬁcant past medical problems and has a height of 5 feet 6 inches, weight of 146 pounds, and a BMI of 23.7. During her ofﬁce visit, a BP measurement with an aneroid automatic sphygmomanometer revealed a BP of 136/82mmHg.Herphysicalexaminationresults were unremarkable. She reports no history of hypertension and does not recall that her BP was ever checked..
Question: Which of the following is the best next step in the assessment of her BP?
1. Her BP is less than 140/90 mm Hg and hence she is acceptable to proceed with her evaluation with no further testing with regard to evaluation for hypertension
2. Her BP is greater than 130/80 mm Hg, you diagnose her with hypertension, and hence she is not a candidate for donation
3. She likely has white coat hypertension and hence can proceed with further evaluation with no further testing with regard to evaluation for hypertension
4. She should complete a 24-hour ambulatory BP monitoring to decide whether or not she has hypertension
Answer: D
Subject: Transplantation

You are seeing a 23-year-old man to evaluate him as a living kidney donor to his mother, who he reports as being attributed to hypertension. He has no signiﬁcant medical history. On examination, he is noted to have a BP of 120/80 mm Hg and a BMI of 29. His physical examination results are unremarkable. His laboratory test results, including urinalysis, urine albumin-to-creatinine ratio, and urine protein-to-creatinine ratio are normal. You contact his mother’s nephrologist and ﬁnd out that she her kidney biopsy specimen showed focal and global sclerosis. The recipient’s team had performed a next-generation sequencing renal genetic testing to ﬁnd that she was heterozygous for abnormal COL4A4 and APOL1 gene renal risk variants..
Question: Which of the following is the next best step in your evaluation of this living donor candidate?
1. Proceed with further evaluation without any genetic testing because his normal results of urinalysis and urine albumin excretion preclude risk for development of kidney disease because of gene abnormalities found in his mother
2. Proceed with genetic testing without informing him and with an intention to discuss test results only if they come back as positive
3. Discuss potential risks and beneﬁts of genetic testing with him now, and proceed with genetic testing only if he agrees
4. Decline him as a candidate because he is at an unacceptable risk for ESKD after donation
Answer: C
Subject: Transplantation

A 56-year-old woman is being evaluated for living kidney donation to her husband. She has a history of mild depression, for which she takes venlafaxine, which is prescribed by her primary care provider and is the only medication she currently takes. On examination, her BP is 125/78 mm Hg, height 5 feet 2.5 inches, weight 154 pounds, BMI 27.8 and body surface area 1.72 m2. No abnormal ﬁndings are noted on her physical examination. On her laboratory testing, she is noted to have a serum creatinine of 0.83 mg/dl with an eGFR of 78.8 ml/min per 1.73 m2 according to the CKD Epidemiology Collaboration (CKD EPI) formula. She had not had a blood test done in many years..
Question: Which of the following is the best next step in her evaluation with respect to kidney function assessment?
1. Decline her as a candidate because her GFR is ,80 ml/min per 1.73 m2
2. Accept her as a candidate because her age- and gender-adjusted GFR is appropriate for donation
3. Perform a 24-hour urine creatinine collection to further assess her GFR
4. Perform an ultrasound of bilateral kidneys to assess for asymmetry in size
Answer: C
Subject: Transplantation

A 55-year-old woman is being evaluated to be a living kidney donor to her husband. She is a college professor in mathematics and reports no medical history. She has no family members with kidney disease. She does not take any medications. On examination, she has a height of 5 feet 5 inches, weight of 187 pounds, calculated BMI of 31.3, body surface area of 1.93 m2, and BP of 128/78 mm Hg. She has a normal result of physical examination. Her urinalysis is normal, urine albumin- to -creatinine ratio is 7 µg/mg, serum creatinine is 0.68 mg/dl with a CKD EPI eGFR of 98.5 ml/min per 1.73 m2, 24-hour urine creatinine clearance of 120 ml/min per 1.73 m2 on an adequately collected sample; fasting blood glucose is normal..
Question: With respect to her obesity, what is the ONE next best step in her evaluation?
1. Because her BMI is > 30, she should be declined as a living kidney donor because of the unacceptable risk for future ESKD after donation
2. Because her BMI is < 35, she should be accepted as a living kidney donor because there is no increased risk for future ESKD after donation compared with normal weight candidates
3. Counsel her on her higher relative risk for future ESKD after donation compared with normal weight candidates but low overall absolute risk
Answer: C
Subject: Transplantation

A 28-year-old woman is being evaluated for living kidney donation. Her only medical history is hypothyroid-ism, which is well controlled with levothyroxine. On examination, she has a BP of 123/73 mm Hg, height of 5 feet 6 inches, weight of 180 pounds, BMI of 29.2. The results of her entire laboratory testing, social work evaluation, and evaluation by independent living donor advocate were acceptable for donation. Her serum creatinine is 0.62 mg/dl with a CKD EPI eGFR of 124 ml/min per 1.73 m2, 24-hour urine creatinine clearance of 131 ml/min per 1.73 m2 on an adequately collected specimen. Her CT angiogram identiﬁed that kidneys were 12.5 cm each, a nonobstructing 4-mm stone was in right kidney, and single renal artery on both sides. She does not describe any history of kidney stones in herself and her family members. A nuclear medicine split renal scan identiﬁed right kidney and left kidney with 47% and 53% of split GFR, respectively..
Question: Which ONE of the following statements reﬂects the BEST next step?
1. Decline her as a candidate because of the presence of nephrolithiasis owing to increased risk of future ESKD after donation
2. Accept her to donate either right or left kidney and recommend that she follow up with her primary care physician for further evaluation
3. Perform a 24-hour urine stone proﬁle, and if it is normal, accept for right donor nephrectomy
4. Perform a 24-hour urine stone proﬁle, and if it is normal, accept for left donor nephrectomy
Answer: C
Subject: Transplantation

A 60-year-old woman donated 6 months ago to her 65-year-old husband, who has ESKD due to diabetes. She is normotensive with no evidence of diabetes or dyslipidemia. Her preoperative electrocardiogram showed normal sinus rhythm..
Question: Which ONE of the following statements would be MOST appropriate in counseling this woman?
1. Cardiovascular death is not the main cause of death among living kidney donors
2. She should have annual or biannual stress test to evaluate for coronary artery disease
3. Living kidney donors have an increased risk of death and major cardiovascular events compared with healthy, nondonor control individuals within the ﬁrst decade of donation
4. Living kidney donors have an increased risk of cardiovascular death and ischemic heart disease compared with healthy, nondonor control individuals after the ﬁrst decade of donation
Answer: D
Subject: Transplantation

A 39-year-old man with a medical history of ESKD secondary to hypertension and on hemodialysis since November 2012, currently listed active for transplantation, receives a kidney offer from a 22-year-old deceased donor with a history of seizure (noncompliant with medication). Donor history: no surgical history. Social history: smoked one or two cigarettes a month since age 16, drank one or two beers on the weekends. Cause of death: asphyxiation. BMI 28.46, blood type O, Kidney Donor Proﬁle Index 19%, urine toxicology negative, terminal creatinine 1.2 mg/dl, HbA1C 5.8%, cytomegalovirus IgG positive, Epstein-Barr virus IgG negative. Nasopharyngeal SARS-COV-2 PCR negative, bronchoalveolar SARS-COV-2 PCR negative, rectal SARS-COV-2 PCR positive. Upon further history, the donor family reports that he had ﬂulike symptoms 4 weeks before his death. Recipient calculated panel reactive antibody (cPRA) class I 70%, class II 0%, no donor-speciﬁc antibody. T cell and B cell ﬂow crossmatch, negative..
Question: Which ONE of the following would be the MOST appropriate approach for this offer?
1. Decline the offer because of donor’s history of ﬂu-like symptoms 4 weeks before his death
2. Acceptable donor, proceed with transplantation
3. Decline the offer because of donor’s positive SARS-COV-2 in the rectum
4. Decline the offer because of high cPRA
5. Decline the offer until COVID pandemic resolves
Answer: B
Subject: Transplantation

A 60-year-old man with a history of ESKD, status post deceased donor kidney transplantation in 2009, heart failure with preserved ejection fraction, hypertension, hyperlipidemia, type 2 diabetes mellitus, and pericardial window in 2007 presented to the emergency department because of shortness of breath and fever for the previous 2 days. He went to an urgent care facility, where he was found to be hypoxic and positive for SARS-CoV-2 infection and was sent to the emergency department for further workup and management. He is on tacrolimus 2 mg twice a day, mycophenolate mofetil 500 mg twice a day, and prednisone 5 mg daily for immunosuppression. In the emergency department, his vital signs were signiﬁcant for BP 145/78, heart rate 98 beats/min, temperature 100.8F, oxygen saturation 87% on room air initially but improved to 97% on 2 liters nasal cannula. Laboratory tests showed white blood cell 3.400/µl (lymphocytes 200/µl), hemoglobin 10.1 g/dl, platelets 125,000/µl, C-reactive protein 4.4 mg/dl, D-dimer 2.47 µg/ml. Chest X-ray revealed mild con-gestion and left lower lobe pneumonia..
Question: Which ONE of the following treatments is NOT recommended for treatment of COVID-19 disease in this patient?
1. Consideration of reduction in immunosuppression
2. Monoclonal antibodies
3. Remdesivir
4. Dexamethasone
Answer: B
Subject: Transplantation

A 69-year-old Hispanic man with ESKD secondary to polycystic kidney disease received a deceased donor kidney transplant 5 years ago. His post-transplantation course was complicated by multiple urinary tract infections and concomitant AKI leading to chronic allograft injury with baseline serum creatinine of 1.8 mg/dl (normal range < 1.3 mg/dl). His medical history includes coronary artery disease and hypertension. He is admitted to the hospital with multifocal pneumonia secondary to SARS-CoV-2 and currently receives supplemental oxygen 3 L/min via nasal cannula to maintain a SpO2 of 94%. His mycophenolate mofetil was held, and he was continued on tacrolimus with target trough levels of 3 to 5 ng/ml and prednisone 5 mg daily. His blood work on admission showed a serum creatinine of 2.5 mg/dl and white blood cell count of 3,500/µl (normal range: 4,800–10,800 /µl) with lymphocyte count of 600/µl (normal range 1,000–4,800/µl. He was started on dexamethasone treatment. Which ONE of the following factors has NOT been associated with increased risk of mortality in transplant recipients with COVID-19? 1. Age
2. Acute kidney injury
3. Cause of kidney disease
4. Lymphopenia
5. History of coronary artery disease
6..
Question: Oxygen requirement
1. Age
2. Acute kidney injury
3. Cause of kidney disease
4. Lymphopenia
5. History of coronary artery disease
Answer: C