SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Interventional Nephrology & Dialysis Therapy
A 45-year-old woman with ESRD is evaluated 2 weeks before scheduled surgery for HD access. Arteriovenous graft placement is planned based on the ﬁndings of preoperative vascular ultrasonography. Her surgeon asks you whether she would beneﬁt from extended-release dipyridamole plus aspirin after graft placement..
Question: Which ONE of the following should you tell the surgeon about the expected beneﬁt of using extended-release dipyridamole plus aspirin after arteriovenous graft placement?
A. Its use will be associated with a clinically meaningful prolongation of the duration of primary unassisted graft patency
B. Its use will be associated with no clinically meaningful increase in arteriovenous graft patency
C. Its use will improve cumulative patency and decrease graft failure at 1 year
D. Its use will have no effect on graft outcomes
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
A 45-year-old woman with ESRD who is receiving maintenance HD through a left fore-arm arteriovenous graft is noted to have had increasing venous pressures and declining urea clearance over the past month. A shuntogram shows a 70 percent stenosis at the venous anastomosis. Angioplasty of the lesion is per-formed, and a stent graft is placed at the venous anastomosis..
Question: Which ONE of the following outcomes is predicted from stent graft placement at the venous anastomosis after angioplasty versus angioplasty alone?
A. No beneﬁt of stent graft placement com-pared with angioplasty alone
B. Superior patency at 6, 12, and 24 months
C. Increased requirement for subsequent interventions for stenosis at the venous anastomosis at 6 months after stent graft placement
D. Higher rate of adverse events after stent graft placement
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
A 58-year-old man with ESRD due to IgA nephropathy who is currently receiving maintenance home HD is evaluated during a routine monthly home therapies clinic visit. He received a kidney transplant 10 years ago that failed 5 years ago. Thrombosis occurred in a right forearm arteriovenous ﬁstula at the time of the transplantation. A right upper arm arteriovenous ﬁstula was created several months ago. He has been successfully using the access for home HD 5 days per week over the past 2 months. Blood ﬂows above 450 ml/min have yielded high venous pressures, but no problems have been encountered at lower blood ﬂow rates. On physical examination, he is obese. His body mass index is 41 kg/m2. Extensive collateralization is noted over the right side of his chest. His right arm has minimal edema. The ﬁstula has a strong thrill, and it collapses when raised above the level of the heart. A ﬁstulogram and central venography show bilateral brachiocephalic vein occlusion with extensive collateralization. His laboratory studies show that he is meeting urea clearance targets and that his acid-base balance, electrolytes, and CKD mineral and bone disorder chemistry results are acceptable..
Question: Which ONE of the following is the next BEST step in management?
A. Treat the left brachiocephalic vein occlusion using radiofrequency wire recanalization
B. Establish a new catheter access using the “inside-out” technique and place a hybrid–graft catheter
C. Stop using the ﬁstula, do not intervene on the central venous occlusions, and transition the dialysis access to a translumbar catheter
D. Continue to use the ﬁstula with blood ﬂows < 450 ml/min
Answer: D
Subject: Interventional Nephrology & Dialysis Therapy
A 68-year-old man with stage 5 CKD is seen in the outpatient clinic 2 weeks after surgery for a left radiocephalic end-to-side ﬁstula. On physical examination, the ﬁstula is noted to have hyperpulsatility at the arterial anastomosis, a thrill 3 cm from the anastomosis, and a small caliber outﬂow vein. Ultrasonography of the ﬁstula shows a juxta-anastomotic stenosis. He asks about the signiﬁcance of this ﬁnding..
Question: Which ONE of the following should you tell him about the signiﬁcance of the juxta-anastomotic stenosis seen on ultrasonography?
A. It is associated with an increased risk of unassisted ﬁstula maturation failure in comparison with no stenosis
B. The stenosis will persist on repeated ultrasonographic imaging at 6 weeks
C. It carries a higher risk for unassisted maturation failure in comparison with distal stenoses
D. It is more likely to be associated with intimal hyperplasia when compared to distal stenoses
Answer: A
Subject: Interventional Nephrology & Dialysis Therapy
You have recently been appointed medical director of your practice’s dialysis program. The program uses measurement of access ﬂow as its surveillance strategy. The staff requests that you provide education about the various methods of access surveillance..
Question: Which ONE of the following should you tell them regarding the diagnostic accuracy of available surveillance methods?
A. Surveillance methods are equally sensitive in identifying both inﬂow and outﬂow stenosis in both ﬁstula and graft
B. Identiﬁcation of access ﬂows < 650 ml/min is the best method to detect outﬂow stenosis
C. The optimal tests for identifying an inﬂow stenosis are access ﬂows < 650 ml/min or the combination of a positive physical examination result plus access ﬂows < 650 ml/min
D. Combining physical examination results with a venous access pressure ratio > 0.5 improves diagnostic performance of the tests in detecting outﬂow stenosis
Answer: C
Subject: Interventional Nephrology & Dialysis Therapy
A 42-year-old woman with ESRD due to lupus nephritis who is receiving maintenance in-center HD is evaluated during dialysis rounds. The dynamic and derived static venous pressures of the left brachiocephalic ﬁstula have recently risen to > 0.55. On physical examination, the ﬁstula has a smooth thrill with good augmentation, and there is absence of partial vein collapse upon arm elevation. A ﬁstulogram identiﬁes a 60 percent outﬂow stenosis that is successfully treated with angioplasty..
Question: Which ONE of the following is the MOST likely outcome of this intervention?
A. A signiﬁcantly reduced risk of permanent access loss
B. A reduced risk of subsequent ﬁstula thrombosis
C. A reduced rate of subsequent surgical interventions
D. An increased rate of complication-related hospitalizations
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
A 72-year-old man with ESRD due to diabetic nephropathy who is receiving maintenance HD is found to have a thrombosed arteriovenous ﬁstula upon presentation to his usual scheduled dialysis treatment on a Friday before a holiday weekend. The dialysis staff refer the patient to the local emergency department. He is asymp-tomatic. On physical examination, his weight exceeds his dry weight by 2 kg. His blood pressure is 136/80 mm Hg. The lung ﬁelds are clear, and there is trace pedal edema. Laboratory studies show a potassium of 5.2 meq/L and a total CO2 of 20 mmol/L. He is admitted for observation, and a ﬁstula thrombectomy is scheduled for the following Tuesday (4 days later) because interventional services are not available on Monday. You are concerned about delaying dialysis and contact the interventional radiologist in an attempt to expedite the pro-cedure. The radiologist offers catheter placement tomorrow. You express concerns about delaying endovascular thrombectomy..
Question: Which ONE of the following should you tell the radiologist regarding outcomes in delaying ﬁstula thrombectomy?
A. Immediate procedural success is more likely when thrombectomy is performed within 24 hours of the time of thrombosis diagnosis
B. Patients undergoing ﬁstula thrombectomy within 24 hours of diagnosis have higher patency rates at 3 months than do patients treated later
C. Thrombectomy performed > 48 hours after thrombosis diagnosis is associated with higher rates of complications
D. Thrombectomy performed > 48 hours adversely inﬂuences his ﬁstula patency at 3 and 6 months because of his diabetes diagnosis
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
A 73-year-old woman with stage 5 CKD decides to pursue PD. Her past surgical history includes two Caesarean sections and an un-complicated laparoscopic appendectomy. She is curious about the PD catheter placement procedure, and she wonders whether her prior surgeries will complicate or preclude catheter placement..
Question: Which ONE of the following should you tell her about PD catheter placement?
A. Percutaneous placement is contraindicated because of her prior appendectomy
B. Advanced laparoscopic placement has the lowest mechanical complication rate
C. Advanced laparoscopic placement is associated with an increased risk for subsequent need to change her modality to HD
D. Fluoroscopic catheter placement has a superior rate of 1-year overall catheter survival compared with advanced laparoscopic catheter placement
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
A 56-year-old man with stage 5 CKD due to diabetic nephropathy is seen in follow up 1 week after PD catheter insertion. He has increased fatigue, loss of appetite, and dysguesia. He asks about the optimal timing for initiation of PD..
Question: Which ONE of the following should you tell him based on the Timely PD study?
A. Patients starting PD one week after catheter placement had signiﬁcantly higher leaks in comparison with patients who started after 2 weeks
B. Patients starting PD 1 week after catheter placement had signiﬁcantly higher leaks in comparison with patients who started after 4weeks
C. Patients with diabetes waiting 4 weeks after catheter placement to initiate PD had higher success with the technique
D. Embedded catheters were a signiﬁcant part of the study
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
Question: Question 2691:
Which ONE of the following statements about predialysis education is CORRECT?
A. Patient-targeted educational interventions increase the odds of receiving PD as the initial treatment modality
B. Unplanned or planned dialysis initiation does not affect patient outcomes
C. Patients with unplanned dialysis initiation do not beneﬁt from education about therapy options
D. Small group dialysis option education does not affect the rate at which patients choose PD
Answer: A
Subject: Interventional Nephrology & Dialysis Therapy
A 42-year-old man receiving maintenance HD is dialyzed through a left upper extremity brachiocephalic ﬁstula. During weekly rounds, you notice that he is wearing a glove on his left hand. He indicates that he has had pain and numbness in the left hand over the past 3 weeks and that his symptoms worsen during dialysis. His blood pressure is 130/80 mmHg. A physical examination reveals that his hand is slightly cool to touch. The left radial pulse is normal. There are no necrotic or ischemic ulcers. His left hand strength and sensation are normal. You suspect arteriovenous access ischemic steal syndrome..
Question: Which ONE of the following is the MOST appropriate next step in management?
A. Ultrasonographic ﬂow measurements and left arm arteriogram
B. Recommend hand-grip exercises only
C. Start amlodipine and aspirin
D. Referral for immediate surgical ligation
E. Change his dialysis access to a tunneled central venous catheter and monitor the left hand
Answer: A
Subject: Interventional Nephrology & Dialysis Therapy
A 67-year-old man with stage 4 CKD is seen in consultation in the surgical intensive care unit for oliguric AKI after emergency cholecystectomy for necrotizing cholecystitis. He requires initiation of intermittent HD for progressive ﬂuid overload. A right internal jugular vein catheter is placed at the bedside under ultrasonographic guidance. He has a history of heparin-associated thrombocytopenia. The catheter is locked with a concentrated solution of trisodium citrate (46.7 percent). Several hours later he experiences perioral numbness, confusion, tachypnea, and hand paresthesias. The oxygen saturation is stable at 92 percent on ambient air. On physical examination, he is somewhat agitated and anxious. His blood pressure is 110/80 mmHg, his respiratory rate is 24/min, his heart rate is 96/min, and his temperature is 36.7C. Auscultation of the chest reveals symmetric breath sounds. There is 1+ peripheral edema. The surgical incision is without erythema or induration. A Trousseau sign is present. The remaining results of the examination are unremarkable. A basic metabolic panel shows sodium 143 meq/L, potassium 5.6 meq/L, chloride 96 meq/L, total CO2 29 mmol/L, BUN 96 mg/dl, and creatinine 5.6 mg/dl. The arterial blood gas shows pH 7.48, PCO2 32 mmHg, and PO2 82 mmHg. An electrocardiogram shows normal sinus rhythm with a prolonged QTc interval of 0.5 milliseconds..
Question: Which ONE of the following is the MOST likely cause of his symptoms?
A. Pulmonary embolus
B. A complication from use of the citrate lock solution
C. A panic attack
D. Venous air embolism
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
You are contacted by the dialysis staff for recommendations regarding the management of HD catheter dysfunction. The patient is a 56-year-old woman with ESRD due to focal and segmental glomerulosclerosis. She has exhausted all options for HD access and is currently dialyzed through a right femoral tunneled central venous catheter. Over the past two dialysis treatments, the catheter has been functioning poorly, delivering blood ﬂows of < 300 ml/min. The blood ﬂows do not improve after instillation of intracatheter thrombolytic therapy that dwelled for 48 hours..
Question: Which ONE of the following is the MOST appropriate next step in management?
A. Remove the catheter and place a translumbar or transhepatic catheter
B. Flush the catheter with isotonic saline solution
C. Exchange the tunneled catheter over a guide wire followed by warfarin anticoagulation
D. Exchange the tunneled catheter over a guidewire with balloon angioplasty to disrupt the ﬁbrin sheath
Answer: D
Subject: Interventional Nephrology & Dialysis Therapy
A dialysis technician asks you to examine a patient’s access before cannulation. The patient is a 53-year-old man with ESRD due to diabetic kidney disease on in-center HD for 7 years. He has been dialyzed via a left upper extremity brachiocephalic ﬁstula since dialysis initiation. Over the years, the diameter of the ﬁstula increased in size. On physical examination, the ﬁstula has hypopigmented, necrotic skin surrounded by thin, shiny skin overlying an area of aneurysm dilation. A small amount of dried blood with minimal fresh oozing of blood is visible at this site..
Question: Which ONE of the following is the BEST next step in management?
A. Advise the technician to avoid cannulation in the areas of breakdown, mark alternative sites for cannulation, and monitor the access closely
B. Refer the patient immediately to the vascular surgeon for evaluation for impending rupture of the arteriovenous access
C. Draw blood cultures and start the patient on empiric antibiotics
D. Apply a pressure dressing, rest the ﬁstula for several weeks, and refer the patient for a tunneled dialysis catheter placement
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
You are discussing dialysis options with a 36-year-old woman with stage 5 CKD due to autosomal dominant polycystic kidney disease. She has a left radiocephalic arteriovenous ﬁstula that has an excellent thrill and that augments and collapses well on examination. She is listed for transplantation but is now symptomatic and ready to begin renal replacement therapy. She is interested in short daily home HD and wants your opinion on the effect of intensive HD on her arteriovenous access..
Question: Which ONE of the following should you tell her regarding management of vascular access during frequent HD?
A. A central venous catheter is the preferred access for frequent HD because it minimizes the risk of needle dislodgement during dialysis
B. Her radiocephalic arteriovenous ﬁstula is an excellent choice for vascular access for intensive HD
C. Recent randomized controlled trials suggest that intensive HD does not increase the risk of vascular access events
D. An immediate-use arteriovenous graft is preferable to a standard polytetraﬂuoroethylene graft for intensive HD
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
A 32-year-old woman in stage 5 CKD is evaluated at a routine monthly ofﬁce visit. She has fatigue, mild intermittent nausea, and dysguesia. She has maintained her weight, and the results of her current laboratory studies are acceptable. Six weeks ago, she underwent creation of a radiocephalic arteriovenous ﬁstula. On physical examination, the ﬁstula is poorly developed and does not augment well on examination. An ultrasonographic evaluation shows a superﬁcial ﬁstula, with a diameter of 4 mm and blood ﬂow of 350 ml/min..
Question: Which ONE of the following is the MOST appropriate next step in management?
A. Recommend continuing hand grip exercises to assist in ﬁstula maturation because it has not yet had adequate time to mature
B. Refer the patient for a low-dose contrast angiogram, including direct arteriogram
C. Repeated ultrasonographic measurements in 6 weeks to avoid radiocontrast exposure
D. Abandon the ﬁstula, monitor her closely, and place an immediate-use arteriovenous graft or catheter when she needs to start dialysis
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
A 49-year old man is evaluated during HD rounds. He recently began HD through a right internal jugular central venous catheter. He has a nonmaturing radiocephalic ﬁstula that was created 8 weeks ago. On physical examination, the ﬁstula has a weak thrill and does not augment well on examination. A large side-branch accessory vein that is > 60 percent of the diameter of the main ﬁstula takes off within 5 cm of the anastomosis. A thrill persists after occlusion of the ﬁstula downstream from the side-branch vein. You estimate that about 30 to 40 percent of the outﬂow is diverted through the large side-branch vein. He asks for your recommendations regarding the signiﬁcance of the accessory vein and its management..
Question: Which ONE of the following should you tell him about current recommendations regarding accessory veins in nonmaturing ﬁstulae?
A. Accessory veins are signiﬁcant contributors to nonmaturity in ﬁstulas and must always be ligated to allow maturation
B. An accessory vein is usually pathologic and is the result of an alternative channel that develops to bypass a stenotic area
C. In nonmaturing ﬁstulas, accessory veins should be ligated if they divert> .25 percent of the outﬂow
D. Accessory veins are a common cause of late ﬁstula failure, and surgical ligation is preferred over endovascular coil placement
Answer: C
Subject: Interventional Nephrology & Dialysis Therapy
A 46-year-old woman with type 1 diabetes mellitus and hypertension who has required HD for the past 12 years is evaluated for permanent HD access. She has had a left forearm radiocephalic ﬁstula that never matured, a left upper extremity brachiobasilic ﬁstula, and a left upper extremity arteriovenous graft, all of which are thrombosed. No upper extremity veins are visible on physical examination. She has scars of previous central venous catheters on both sides. Venous mapping by ultrasonography on the right arm shows a 2.6-mm radial artery and a 3.2-mm brachial artery. The cephalic vein is not visible in the forearm but measures 3.2 mm at the elbow, 3.6 mm at the midarm, and 4.2 mm at the upper arm. The basilic vein measures 3.4 mm at the elbow and 4.8 mm in the axilla. Both veins are compressible throughout their course..
Question: Which ONE of the following is the BEST next step in management?
A. Plan right brachiocephalic ﬁstula
B. Plan a right forearm arteriovenous graft to allow veins in the upper extremity to develop for a secondary ﬁstula
C. Plan contrast venography of her central veins to evaluate for unsuspected central venous stenosis
D. Plan a right brachiobasilic arteriovenous ﬁstula because the cephalic vein is not visualized in the forearm
Answer: C
Subject: Interventional Nephrology & Dialysis Therapy
A 78-year-old man is evaluated because of a 2-month history of progressive generalized weakness, decreased appetite, nausea, and difﬁculty urinating. On physical examination, he is bradycardic and hypertensive. He has mild hypervolemia but is not in acute respiratory distress. Further evaluation shows a serum creatinine level of 11 mg/dl, anemia, hyperkalemia, and metabolic acidosis. The ﬁndings on bedside kidney ultrasonography show dilated  pelvis in the right kidney..
Question: Which ONE of the following diagnoses BEST describes the ultrasonography ﬁndings?
A. Renal masses
B. Hydronephrosis
C. Dilatated renal vessels
D. Acquired cystic disease of the kidney
E. Autosomal dominant polycystic kidney disease
Answer: B
Subject: Interventional Nephrology & Dialysis Therapy
You hire two advanced practice providers without experience in dialysis care to assist in the treatment of patients in your dialysis program. They are interested in learning about physical examination ﬁndings that indicate arteriovenous ﬁstula access stenosis..
Question: Which ONE of the following ﬁndings should you tell them is associated with inﬂow stenosis?
A. Edema in the access arm
B. A high-pitched systolic bruit in the proximal venous segment of the access
C. Absence of venous collapse upon arm elevation
D. A discontinuous thrill with only a systolic component at the juxta-anastomotic site
E. Augmentation of the pulse on ﬁstula occlusion
Answer: D
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

You are asked to evaluate a 73-year-old retired dentist who has CKD secondary to focal and segmental glomerulosclerosis. He was ﬁrst seen 3 years ago when his serum creatinine level was 2.3 mg/dl (eGFR 28 ml/min per 1.73 m2). He had received steroid therapy, and his hypertension has been managed with angiotensin blockade. He has not returned to your ofﬁce for the past 2 years. One year ago, he had a myocardial infarction, requiring an angioplasty and has been followed up regularly by his cardiologist for control of hypertension and hypercholesterolemia. You obtain laboratory values, which reveal that his serum creatinine is now 2.8 mg/dl (eGFR 22 ml/min per 1.73 m2), serum calcium is 9.0 mg/ml, phosphorus is 3.6 mg/dl, alkaline phosphatase is 100 U/ml (reference range 36–92 U/ml), and intact PTH is 122 pg/ml (reference range 12-72 pg/ml). The 25-hydroxyvitamin D level is 30 ng/ml (reference range 20–80 ng/ml). The serum albumin is 3.6 g/dl, and the urine protein-to-creatinine ratio is 900 mg/g..
Question: Which ONE of the following is the MOST appropriate management?
1. Cholecalciferol 2000 units daily
2. Calcifediol 30 mg daily
3. No further evaluation or therapy is required
4. Start a phosphate binder
5. Start calcitriol 0.25 µg per day
Answer: C
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 64-year-old man with ESRD has been receiving hemodialysis for 2 months and transfers to your unit. The initial laboratory values show that serum calcium is 10.2 mg/dl, the phosphorus is 5.7 mg/dl, the serum PTH is 594 pg/ml, and the alkaline phosphatase is 214 U/ml (reference range 36–92 U/ml). He had been prescribed sevelamer carbonate 2400 mg three times daily with meals..
Question: Which ONE of the following is the next BEST step in management?
1. Begin therapy with calcitriol 2 µg IV with each dialysis
2. Begin cinacalcet therapy 30 mg daily
3. Add lanthanum carbonate 1 gram 3 times daily with meals
4. Begin paricalcitol 4 µg with each dialysis
Answer: B