SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: End-Stage Kidney Disease

As part of a quality improvement initiative at your PD unit, you have arranged to meet with the surgical team to review protocols for PD catheter insertion at your hospital. Your surgeons have traditionally placed PD catheters using an open surgical technique and are considering a switch to laparoscopic technique. In advance of this meeting, you will circulate a document summarizing recent studies in this area, and include discussion points to review during the meeting..
Question: In planning your PD new catheter placement protocol, which one of the following statements is correct?
1. Embedded PD catheters are associated with higher rates of exit site infections
2. Laparoscopic placement of PD catheters is recommended because it has been clearly associated with superior out-comes when compared with open surgical placement
3. A recent randomized controlled trial showed that straight PD catheters have higher rates of dysfunction than coiled PD catheters
4. No differences have been found in rates of complications such as peritonitis and exit site infections when straight and coiled PD catheters have been compared
Answer: D
Subject: End-Stage Kidney Disease

A 54-year-old man with ESKD secondary to IgA nephropathy started on automated PD 3 months ago. Despite escalating doses of antihypertensives, his BP control has been worsening over the past few months, and his home readings currently average at 168/96 mmHg. He has well-maintained RRF and makes > 600 ml urine per day. His physical examination result is unremarkable and without overt signs of ﬂuid overload. When you suggest changing his PD prescription to increase his UF, he replies that he does not feel over-loaded and prefers to increase his medication further..
Question: When managing BP and volume status in PD patients, which of the following is correct?
1. Bioimpedance studies suggest that ﬂuid overload is more common in HD patients than PD patients
2. Risk factors for ﬂuid overload (as measured by bioimpedance spectroscopy) in PD patients include hypoalbuminemia and diabetes
3. Management of ﬂuid status using bioimpedance data has been shown to improve outcomes for patients on PD
4. In patients initiating PD, higher BPs have been associated with increased mortality rates
Answer: B
Subject: End-Stage Kidney Disease

A 63-year-old woman with ESKD secondary to ANCA vasculitis has been on PD for 1 year. She is currently listed for renal transplantation, with 2 years of wait time. When she initiated PD, she had excellent RRF, but over the past few months, her urine output has begun to decline. She is keen to stay on PD until she receives a transplant, and she understands the importance of RRF to successful PD. She asks what can be done to protect her remaining kidney function..
Question: In considering strategies to maintain RRF in PD patients, which of the following is correct?
1. Use of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker has been associated with lower rates of cardiovascular mortality but faster loss of RRF
2. Exposure to PD ﬂuids containing high concentrations of glucose has been associated with faster loss of RRF
3. Bioimpedance studies suggest that maintaining mild volume expansion may protect against loss of RRF in PD patients
4. Studies have not shown a beneﬁt of biocompatible PD solutions over conventional PD solutions for preservation of RRF
Answer: B
Subject: End-Stage Kidney Disease

A 63-year-old man with ESKD secondary to polycystic kidney disease has been on PD for 4 years, He was recently admitted with chest pain and received a diagnosis of non-ST-segment elevation myocardial infarction, He has been discharged on ap-propriate secondary prevention and comes to your ofﬁce for a postadmission visit. When reviewing his case, you see that his home BPs average at 134/88 mmHg, and his recent LDL was 64 mmol/L..
Question: When considering this patient’s risk factors for cardiovascular outcomes and mortality, which of the following is correct?
1. Hyperlipidemia has been associated with increased mortality in PD patients
2. Monitoring of home BP has been associated with improved clinical outcomes
3. Prospective studies have failed to show a correlation be-tween RRF and mortality in PD patients
4. During the past decade, mortality rates for patients on PD declined more quickly than rates for HD patients
Answer: D
Subject: End-Stage Kidney Disease

A 60-year-old man with ESKD has been on home HD (HHD) using the NxStage System One at home for 1 year. He uses a left forearm ﬁstula. He has been clinically stable during and after HD. His BP is well maintained throughout dialysis. * Medical history: IgA nephropathy, hypertension, no diabetes or coronary artery disease. * Dialysis prescription: dry weight 72 kg, 3 hours 5 days per week, total weekly UF volume 8 L. Calculated standard Kt/Vurea per week 2.3. * Dialysate composition: [Na] 140 mEq/L, [K] 2 mEq/L, chloride 101 mEq/L, [Ca] 3 mEq/L, lactate 45 mEq/L. * Laboratory tests are done before HD monthly; this time, la-boratory tests after HD were done as well. * Before HD: creatine 6.2 mg/dl (548 µmol/L), Na 136 mEq/L, K 5.4 mEq/L, Cl mEq/L 98, total carbon dioxide (tCO2) 24 mEq/L, anion gap 14. * After HD: creatinine 3.5 (309 µmol/L), Na 137 mEq/L, K 3.6 mEq/L, Cl 99 mEq/L, tCO2 20 mEq/L, anion gap 18. * Normal liver function test results..
Question: Why is the serum bicarbonate lower after HD than before HD?
1. Possible laboratory error
2. Drug overdose
3. Ketoacidosis
4. Lactic acidosis related to organ ischemia or liver disease
5. The patient has lactic acidosis as a result of the presence of lactate as a buffer in the dialysate
Answer: E
Subject: End-Stage Kidney Disease

A 70-year-old man on HHD has used the NxStage System One for 4 years. He has been feeling tired, has poor appetite, and has lost 2 kg over the past year. He is anuric. Dialysis prescrip-tion: 2.5 hours 5 days per week, Dialysate volume 30 L, calculated standard Kt/Vurea per week 1.9, dry weight 110 kg. Week-ly UF 13 L. Laboratory test results before HD: creatinine 16.2 mg/dl (1432 mmol/L), Na 136 mEq/L, K 5.9 mEq/L, Cl 98 mEq/L, tCO2 22 mEq/L, calcium 9.6 mg/dl (2.4 mmol/L), phosphate 7.5 mg/dl (2.5 mmol/L), albumin 3.3 g/dl (33 mg/L). He is on calcium carbonate phosphate binders, which he does not tolerate well. He is on three antihypertensive medications. You are concerned about possibly inadequate dialysis dose as the cause of the patient’s problem. Therefore, you have selected as a goal a weekly standard Kt/Vurea of 2.4..
Question: Which of these prescriptions or modalities would best address the clinical issues described here?
1. Convert to nocturnal HD 7 hours 5 times per week at the same dialysate volume of 30 L
2. Dialyze for 4 hours ﬁve times per week
3. Convert to in-center HD 4 hours three times per week
4. Convert to PD
Answer: A
Subject: End-Stage Kidney Disease

A 56-year-old man received his second kidney transplant 9 years ago. His kidney function has been declining related to transplant glomerulopathy. His medical history includes diabetes mellitus, hypertension, and coronary artery disease. He had two previous myocardial infarctions and one episode of congestive heart failure, leading to hospitalization. He was told that he will need dialysis within the next few months. On an echocardiogram he has eccentric left ventricular hypertrophy, and his left ventricular ejection fraction is 33%. He is highly presensitized, and therefore a new kidney transplant is not expected soon. The patient is asking about his dialysis options..
Question: Which of the following is true regarding nocturnal HHD?
1. BP control is likely to be slightly worse compared with three-times-weekly in-center HD
2. The Frequent Hemodialysis Network extended trial conclusively demonstrated that nocturnal HD results in lower mortality
3. He may not need to use phosphate binders with nocturnal HD
4. His left ventricular hypertrophy will likely worsen on intensive HD
Answer: C
Subject: End-Stage Kidney Disease

A 42-year-old woman has advanced CKD level 5, approaching renal replacement therapy. She does not a have a live donor for a pre-emptive kidney transplantation. She is considering some of the home dialysis options, speciﬁcally HHD. She is asking what type of dialysis other patients choose in the United States..
Question: What is the use of HHD in the United States?
1. The approximate number of prevalent patients in the United States is PD 60,000 and HHD 10,000
2. The incidence rate of HHD is 5%
3. The prevalence rate of HHD is 8%
4. There was a signiﬁcant increase in HHD uptake during the COVID-19 pandemic
Answer: A
Subject: End-Stage Kidney Disease

A 34-year-old man with ESKD related to IgA nephropathy is awaiting deceased donor kidney transplantation. He teaches physiology at a local community college. He has been on conventional in-center HD for 2 years. However, he used to be a triathlete and is interested in intensive HHD to allow him to resume competition. He has read about HHD and asks you about the beneﬁts..
Question: Which of the following beneﬁts are associated with HHD compared with PD and transplantation?
1. HHD has been associated with improved survival compared with both living and deceased donor transplantation
2. HHD is associated with improved survival compared with living but not deceased donor transplantation
3. HHD is associated with improved survival compared with deceased donor but not living donor transplantation
4. HHD has been associated with improved survival com-pared with PD in patients who have been on in-center HD for longer than 1 year
Answer: D
Subject: End-Stage Kidney Disease

You are asked to give a talk to the chief medical ofﬁcer of your hospital in anticipation of possible changes in the use of home kidney replacement therapies as a result of the COVID-19 pandemic..
Question: Which of the follow is true regarding HHD?
1. Use of PD but not HHD, increased during the COVID-19 pandemic
2. Use of HHD, but not PD, increased during the COVID-19 pandemic
3. Pre-emptive transplantation, but neither HHD nor PD in-creased during the COVID-19 pandemic
4. The use of all home therapies increased during the COVID-19 pandemic
Answer: A
Subject: End-Stage Kidney Disease

A 59-year-old patient with stage 5 CKD requests a second opinion with you to discuss the possibility of home dialysis..
Question: According to recent data, which of the following is the most signiﬁcant barrier to patients switching to home dialysis?
1. The amount of medical and procedural supervision avail-able to the patient
2. Relative cost of therapies
3. The utility of the standard Kt/Vurea in determining the prescription
4. The relative effect of home therapies on phosphate
Answer: A
Subject: End-Stage Kidney Disease

While rounding at the in-center dialysis unit you meet with a 75-year-old man with a history of diabetes, coronary artery disease, and peripheral vascular disease after having undergone a left above-the-knee amputation, who has been on dialysis for 6 years. Although he previously lived independently, he has been living in a skilled nursing facility for the past year. This is his ﬁrst dialysis after being discharged from hospitalization with volume overload related to poor UF in the outpatient setting resulting from hypotension, and he required intubation and a stay in the intensive care unit. He met with palliative care in the hospital and completed some advance care planning, including an out-of-hospital “do not intubate and do not resuscitate” form. He ex-plains to you that should he continue to be unable to tolerate UF as an out patient, he would not want to go back to the hospital and would want to discontinue dialysis. He asks how long he would live if dialysis were discontinued..
Question: Which of the following is the most appropriate response?
1. “This is a very serious decision; I would like for you to meet with our social worker to discuss your mood and screen you for depression”
2. “Prognosis varies; however, most experience tells us that on average patients may live about 7 days without dialysis; This may be slightly more or less depending on other medical conditions that someone has, and how much residual renal function one has”
3. “Prognosis is unpredictable, but I would expect you could live for several weeks without dialysis”
4. “That's an excellent question, but unfortunately we do not know enough about prognosis under such circumstances; I will refer you to outpatient palliative care to discuss this decision further”
Answer: B
Subject: End-Stage Kidney Disease

A 72-year-old woman with a medical history of ESKD on maintenance HD, diabetes with neuropathy, hypertension on losartan, and atrial ﬁbrillation on Eliquis is brought to the emergency department by her daughter after being found con-fused at home, unable to recognize family, and appearing disheveled. She has been compliant with her dialysis treatments, and her last treatment was 2 days prior. Although she has neuropathy, it has been controlled on a long-term stable low dose of gabapentin (100 mg three times per week), and she has no history of falls. She has had no fever, chills, or sick contacts. The daughter notes that she was having severe back pain last week, for which she saw her primary care doctor, who prescribed baclofen 10 mg daily. The result of blood work is unrevealing, and CT of the head does not show acute cerebrovascular events..
Question: Which one of the following is the most likely causal agent of her altered mental status?
1. Gabapentin
2. Baclofen
3. Eliquis
4. Losartan
Answer: B
Subject: End-Stage Kidney Disease

As medical director of an outpatient HD unit, you form a committee to decrease 30-day readmissions in your patients. The committee decides to start to focus on identifying patients who are at the highest risk for multiple readmissions. After re-viewing the available evidence regarding “high users” or those with frequent readmissions, you plan a focus on high-risk patient groups to reduce readmission rates..
Question: Which of the following characteristics is most predictive of multiple readmissions in patients receiving HD?
1. Age > 65 years
2. Community dwelling
3. Number of hospitalizations in the past year
4. Recent admission for a noncardiac cause
Answer: C
Subject: End-Stage Kidney Disease

You are consulting in the outpatient ofﬁce on a new patient. He is a 65-year-old man with CKD stage 4 (eGFR 20 ml/min per 1.73 m2) from diabetic nephropathy. His wife accompanies him to the ofﬁce. He notes unintentional weight loss of more than 10 pounds over the last year, complains of poor appetite and exhaustion, and upon evaluation he has slow gait speed and ambulates with a cane. Additionally, his wife notes that he requires help with some activities such as grocery shopping, cooking, and keeping track of medications. They are interested in transplantation referral and a home modality for dialysis..
Question: Which of the following is the patient most likely to experience during his clinical course?
1. He is at decreased risk for hospitalizations or emergency department visits
2. He should be referred for renal transplantation and is at low risk of post-transplantation complications
3. He is at increased risk of having technique failure with a home modality, such as PD
4. He should be initiated on dialysis earlier to help treat the symptoms he is currently experiencing
Answer: C
Subject: End-Stage Kidney Disease

An 85-year-old woman with a history of CKD stage 5 with an eGFR of 8 ml/min per 1.73 m2, dementia, diabetes, peripheral vascular disease, and cardiac disease with a remote history of myocardial infarction is referred to you for evaluation of treatment options for her advanced kidney disease. Her daughter accompanies her to the visit and notes that the patient has re-quired 24-hour care for the past several years and spends most of her days in a chair or bed at home. The daughter re-ports that she had previously discussed dialysis with her mother, and her mother was not interested in pursuing it. Her daughter asks your advice on conservative management of ESKD..
Question: With regard to patients choosing conservative management of ESKD, which of the following is correct?
1. In the last 30 days of life, those who choose conservative management use fewer hospice services
2. In patients of all ages, those who choose dialysis live longer than those choosing conservative management
3. The family members and caregivers of those pursuing conservative management report lower quality of life
4. Those who pursue conservative management spend less time in hospital
Answer: D
Subject: End-Stage Kidney Disease

A 47-year-old woman with ESKD secondary to diabetes mellitus is being discharged after a 3-day inpatient admission for ﬂuid overload and pulmonary edema. This is her third hospitalization within the past 6 months, and she asks whether she would have fewer readmissions if she were on PD..
Question: With regard to readmissions for patients on renal replacement therapy, which of the following is correct?
1. Readmission rates are higher for patients on HD than those on PD
2. In patients who are on HD, the frequency of dialysis after an admission for pulmonary edema affects the rates of readmission
3. The 30-day readmission rate for patients on HD is 45%
4. Hospital admissions early after dialysis initiation do not signiﬁcantly inﬂuence the likelihood of receiving a renal transplant in the second year on dialysis
Answer: B
Subject: Electrolytes and Acid-Base Disorders

A 25-year-old woman with no signiﬁcant medical his-tory participated in a full marathon for the ﬁrst time. After she completed the race in 5 hours, she experienced seizures and was transferred to the emergency department. According to her friend, she had been drinking water frequently at the water stations during the marathon..
Question: Vital signs: Glasgow Coma Scale (GCS): E2V2M2 (Eye response, opens eyes in response to pain; Verbal response, makes sounds; Motor response, extension to painful stimuli); BP 130/76 mm Hg (supine position), pulse rate 70 beats/min, respiratory rate 18/min, SpO2 95% (room air), temperature 36.5 degree C, weight 63 kg (+3 kg more than usual)
Blood: total protein 7.3 g/dl, albumin 4.2 g/dl, BUN 12 mg/dl, creatinine 0.7 mg/dl, uric acid 3.0 mg/dl, Na 121 mmol/L, K 4.0 mmol/L, Cl 87 mmol/L, glucose 250 mg/dl, osmolality 260 mOsm/kg H2O
Urine: osmolality 450 mOsm/kg H2O
Which ONE of the following is the MOST likely cause of this patient’s seizures?
A.        Dehydration
B.        Exercise-associated hyponatremia
C.        Use of nonsteroidal anti-inﬂammatory drugs during marathon training
D.        Hyperglycemia
E.        Volume depletion
Answer: B
Subject: Electrolytes and Acid-Base Disorders

A 21-year-old woman with no signiﬁcant medical history participated in a rave party on a Saturday night. Her friend recommended the use of ecstasy. The patient was dancing and drinking several cocktails, and she gradually became confused and drowsy. Unfortunately, her friend thought that her drowsiness was due to too much alcohol, and she was left unattended. Subsequently, when she became unresponsive, she was transported to the emergency department. Vital signs: GCS: E1V1M1 (Eye response, does not open eyes; Verbal response, makes no sounds; Motor response, makes no movements); BP 100/60 mm Hg (supine position), pulse rate 120 beats/min, respiratory rate 12/min, SpO2 85% (room air), temperature 36.0 degree C, weight 60 kg (+3 kg more than usual)
Blood: total protein 7.5 g/dl, albumin 4.5 g/dl, BUN 25 mg/dl, creatinine 1.1 mg/dl, uric acid 3.0 mg/dl, Na+ 120 mmol/L, K+ 4.5 mmol/L, Cl- 85 mmol/L, glucose 100 mg/dl, osmolality 250 mOsm/kg
Urine: Na+ 120 mmol/L, K+ 30 mmol/L, osmolality 500 mOsm/kg H2O
Computed tomography of brain: cerebral edema
She received a diagnosis of cerebral edema caused by acute hyponatremia resulting from ecstasy..
Question: Which ONE of the following is the MOST appropriate initial treatment for this patient?
A.        Loop diuretic (furosemide) IV (20 mg)
B.        3% NaCl bolus IV (100 mL over 10 minutes up to x 3)
C.        3% NaCl infusion (100 ml/h)
D.        Tolvaptan (15 mg via nasogastric tube)
E.        Urea (30 g via nasogastric tube)
Answer: B
Subject: Electrolytes and Acid-Base Disorders

A 47-year-old man who was a heavy drinker had received a diagnosis of liver dysfunction for the past 5 years. He drank eight to 10 beers per day, and lived alone, reportedly in poor circumstances. He visited the clinic when his family noticed gait instability. Vital signs: GCS: E4V5M6 (Eye response, opens eyes spontaneously; Verbal response, oriented, converses normally; Motor response, obeys commands); BP 120/ 60 mm Hg (supine position), pulse rate 70 beats/min, respiratory rate 14/min, SpO2 98% (room air), temperature 36.5 degree C, weight 59 kg (+2 kg compared with a month before), conjunctiva icteric
Blood: total protein 6.3 g/dl, albumin 3.0 g/dl, BUN 6 mg/dl, creatinine 0.5 mg/dl, uric acid 5.5 mg/dl, Na+ 120 mmol/L, K+ 2.8 mmol/L, Cl- 70 mmol/L, glucose 80 mg/dl, osmolality 260 mOsm/kg H2O
Urine: Na+ 18 mmol/L, K+ 18 mmol/L, osmolality 100 mOsm/kg H2O
He received a diagnosis of chronic hyponatremia with mild symptoms (gait instability) due to beer potomania, and his serum [Na+] was corrected. After 24 hours, his serum [Na+] increased to 132 mmol/L, his K was 3.1 mmol/L, and he had no other symptoms..
Question: Which ONE of the following is the MOST appropriate next step in management?
1. Continue current treatment until his serum [Na+] reaches 135 mmol/L
2. B. Continue the current treatment until all symptoms are eliminated
3. Increase K+ replacement for his hypokalemia
4. Terminate the current treatment and observe the patient carefully
5. Terminate the current treatment and re-lower the serum [Na+] with 5% dextrose in water and desmopressin
Answer: E
Subject: Electrolytes and Acid-Base Disorders

A 38-year-old woman with no signiﬁcant medical his-tory experienced severe nausea, vomiting, and diarrhea for 2 days. She was referred to the emergency department because of weakness and difﬁculty in food intake. Vital signs: GCS: E4V5M6 (Eye response, opens eyes spontaneously; Verbal response, oriented, converses normally; Motor response, obeys commands); BP 90/50 mm Hg (supine position), pulse rate 120 beats/min, respiratory rate 16/min, SpO2 99% (room air), temperature 37.8 degree C, body weight 55 kg (-4 kg). Blood: total protein 7.0 g/dl, albumin 3.8 g/dl, BUN 50 mg/dl, creatinine 1.2 mg/dl, uric acid 8.8 mg/dl, Na 128 mmol/L, K 3.5 mmol/L, Cl 90 mmol/L, glucose 80 mg/dl, osmolality 270 mOsm/kg H2O
Urine: Na+ 15 mmol/L, K+ 15 mmol/L, osmolality 450 mOsm/kg H2O
Volume depletion due to severe vomiting and diarrhea was diagnosed; normal saline was administered to restore her extracellular ﬂuid volume. Subsequently, her condition improved (BP 110/70 mm Hg [supine position]), but serum [Na+] increased to 140 mmol/L within a day..
Question: Which ONE of the following is the MOST likely cause of this patient’s serum [Na+] increase?
1. Extracellular ﬂuid volume replacement by normal saline infusion leading to increased free water excretion (aquaresis)
2. Fluid restriction due to inability to consume ﬂuids orally
3. Increased water losses from sweating
4. Na+ repletion by normal saline infusion
5. Remission of nausea and vomiting, eliminating non-osmotic arginine vasopressin secretion
Answer: A