SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Transplantation

A patient is scheduled to receive a deceased-donor kidney procured in their local area with an expected cold ischemia time (the time from procurement to initiation of transplant vascular anastomosis) of 8 hours, a time far lower than the national average. The kidney is placed on an HMP pump..
Question: In the setting of low cold ischemia time, which ONE of the following is an advantage of HMP pumped kidneys compared with standard cold storage preservation with University of Wisconsin solution?
1. Reduced incidence of delayed graft function
2. Reduced incidence of acute rejection
3. Improved graft survival
4. Reduced mortality
Answer: A
Subject: Transplantation

A 59-year-old African American woman with hypertensive nephrosclerosis is evaluated 3 months after living unrelated kidney transplantation. She is maintained with tacrolimus 4 mg twice daily, myco-phenolate, and prednisone. Her 12-hour tacrolimus trough levels vary between 5 and 12 ng/ml. She experiences of insomnia, tremor, and headaches. You believe her symptoms may be related to tacrolimus, and you suggest transitioning her to once-daily LCP tacrolimus (LCPT) at a dose of 6 mg daily..
Question: Which ONE of the following is TRUE regarding the pharmacokinetics of LCPT compared with immediate release, twice-daily tacrolimus?
1. Lower C maximum (peak concentration) and lower AUC (area under the curve, total exposure
2. Similar C maximum but lower AUC
3. Higher C maximum but lower AUC
4. Lower C maximum but higher AUC
Answer: D
Subject: Transplantation

A 38-year-old man with reﬂux nephropathy and tophaceous gout is evaluated 6 months after a zero-HLA matched living kidney donor transplantation. He is taking tacrolimus, mycophenolate mofetil, prednisone, and allopurinol. He has a BMI of 24 kg/m2, and his serum creatinine has ranged between 1.1 and 1.4 mg/dl. He has had no complications except for persistent neutropenia. Trimethoprim-sulfamethoxazole and valganciclovir were held, and the dose of mycophenolate mofetil was progressively lowered to 250 mg twice daily. Attempts to taper allopurinol failed because of severe ﬂares of gout. He has required ﬁlgrastim injections weekly for the past 3 weeks. He is cytomegalovirus (CMV) IgG negative, and his donor was CMV IgG positive. He has not had CMV viremia by CMV polymerase chain reaction (PCR) assays every 2 weeks for the past 2 months. He has no fever and is asymptomatic..
Question: Which ONE of the following modiﬁcations of maintenance immunosuppression is the MOST appropriate treatment option for this patient?
1. Discontinue tacrolimus, start belatacept
2. Discontinue mycophenolate, start azathioprine
3. Discontinue tacrolimus, start everolimus
4. Discontinue mycophenolate, start everolimus
Answer: D
Subject: Transplantation

A 50-year-old woman with ESRD due to polycystic kidney disease has a cPRA of 50% and has a strongly positive crossmatch with her husband, her only potential living donor. Her blood type is A, and her husband’s blood type is O. She has been on the kidney transplantation waiting list for 2 years. The mean waiting time to transplantation in her region is 3 years..
Question: Which ONE of the following is MOST likely to result in transplantation within the next 6 to 12 months?
1. Desensitization with plasma exchange, IVIG, and rituximab followed by living donor transplantation
2. Entrance into a paired exchange program
3. Continued waiting for a deceased-donor kidney
4. Desensitization with IVIG and rituximab while awaiting deceased-donor transplantation
Answer: B
Subject: Transplantation

A 45-year-old woman with ESRD due to type 2 diabetes mellitus has a cPRA of 88% as a result of prior blood transfusions. Her husband is evaluated and approved as a living kidney donor. Her blood type is O, and he has blood type B. Her anti-B IgG titer is 1:16. She does not have any preformed donor-speciﬁc HLA antibodies to her husband. Given the challenge of ﬁnding an appropriate match in a paired exchange network because of her high cPRA and blood type, and the likely success with plasmapheresis in achieving a negative crossmatch with her husband, an ABO-incompatible transplantation is performed after desensitization. The desensitization protocol includes four plasmapheresis sessions, IVIG after each treatment, and rituximab at the time of transplantation..
Question: Compared with ABO-compatible trans-plantation, which ONE of following outcomes at 1 year is expected in this patient?
1. Decreased risk of antibody-mediated rejection
2. Decreased risk of bleeding complications
3. Decreased risk of infections
4. Increased risk of uncensored graft loss
Answer: D
Subject: Transplantation

A 55-year-old woman who underwent kidney transplantation 18 months ago undergoes allograft biopsy because of a sustained rise in her serum creatinine from 1.4 mg/dl to 1.9 mg/dl over a 3-month period. She has a de novo donor-speciﬁc antibody to HLA A27 (3200 mean ﬂuorescence intensity). The biopsy report describes double contours of the glomerular basement membrane, rare foci of tubulitis with < 4 cells per high power ﬁeld, interstitial inﬂammation involving 25% of the total cortex, areas of interstitial ﬁbrosis with 25% sclerosis of the cortical parenchyma, 2+ peritubular capillaritis with staining for the complement degradation product C4d, but no large vessel inﬂammation or hyalinosis..
Question: Which ONE of the following is the histologic diagnosis?
1. Grade IA chronic active T cell–mediated rejection
2. Acute mixed T cell–mediated and antibody-mediated rejection
3. Acute T cell–mediated rejection
4. Chronic active antibody-mediated rejection
Answer: D
Subject: Transplantation

A 24-year-old man receives a diagnosis of biopsy-proven active antibody-mediated rejection after a period of medication nonadherence. The biopsy specimen is notable for interstitial edema without clear evidence of ﬁbrosis..
Question: Which ONE of the following treatment regimens has the BEST evidence to support its use for the treatment of antibody-mediated rejection?
1. Plasmapheresis and IVIG
2. Plasmapheresis, IVIG, and rituximab
3. Plasmapheresis, IVIG, and bortezomib
4. IVIG and rituximab
Answer: A
Subject: Transplantation

A 46-year-old woman is scheduled to receive a 2-haplotype matched kidney from her younger sister. During her preoperative visit, she asks about the success rates of clinical trials of tolerance induction for someone like her with such a very well-matched kidney donor because she hopes to avoid long-term immunosuppression..
Question: Which ONE of the following should you tell her about tolerance induction?
1. Clinical tolerance has never been successfully induced in human kidney transplant recipients
2. Clinical tolerance has been induced in zero antigen mismatched living donor recipients, although it is durable in only about one-third of patients
3. Demonstration of CD4(+) CD25(high) FOXP3(+) T regulatory cells in peripheral blood fails to predict transplantation tolerance
4.  B cells play no role in the induction and maintenance of clinical tolerance
Answer: B
Subject: Transplantation

A 39-year-old man is evaluated during a routine ofﬁce visit 3 months after living related donor kidney transplantation. The primary disease that led to ESRD was primary focal segmental glomerulosclerosis (FSGS). The urine protein-to-creatinine ratio is found to have risen to 1500 mg/g. A biopsy specimen of the allograft shows recurrent FSGS. The patient asks you about his prognosis..
Question: Which ONE of the following should you tell him about his ﬁndings?
1. Younger age at the time of transplantation is associated with a lower risk of recurrent FSGS
2. Recurrent glomerular disease signiﬁcantly reduces the rate of death-censored graft survival to about 10% at 5 years
3. Subnephrotic-range proteinuria after kidney transplantation does not affect allograft survival
4. Proteinuria after kidney transplantation in-creases the risk of graft failure but not death
5. Recurrent disease is more likely to develop after living related donor transplantation compared with deceased-donor kidney transplantation
Answer: E
Subject: Transplantation

A 69-year-old woman is assessed preoperatively before a scheduled living related donor kidney transplantation next month (her daughter is the donor). She has required resection of two squamous cell carcinomas from her face, both of which were < 1 cm. Review of the pathology report indicates that the margins were clear. Her last skin cancer excision was 3 years ago. She has had ongoing dermatology follow-up examinations annually. Examination of the skin shows no new skin lesions. She asks about the signiﬁcance of her history of skin cancer with respect to her outcomes after transplantation..
Question: Which ONE of the following should you tell her about skin cancer and kidney transplantation?
1. Pretransplantation skin cancer has no impact on the risk of graft failure
2. Pretransplantation skin cancer has no impact on the risk of solid organ malignancy de-velopment after transplantation
3. Pretransplantation skin cancer has no impact on the risk of mortality after transplantation
4. Pretransplantation skin cancer increases the risk of posttransplantation lymphoproliferative disorder
Answer: D
Subject: Transplantation

A 22-year-old woman with ESRD due to renal dysplasia receives a deceased-donor kidney transplant. She is Epstein Barr virus (EBV) seronegative, and her donor is Epstein Barr seropositive (EBV D + /R -). Four months after transplantation, the result of a screening EBV PCR is positive, with a viral load of 4250 copies/ml. She feels well and has no symptoms. She is concerned about this ﬁnding and asks about its signiﬁcance..
Question: In addition to the associated increased risk of posttransplantation lymphoproliferative disorder, which ONE of the following should you tell her?
1. Persistent high-grade EBV viremia is a risk factor for cancer other than posttransplantation lymphoproliferative disorder
2. Patients with EBV viremia during the ﬁrst 6 months after transplantation have equivalent allograft survival compared with EBV-negative patients
3. Patients with late-onset EBV viremia after transplantation are at increased risk of death compared with EBV-negative patients
4. The risk of EBV-associated complications can clearly be mitigated with antiviral therapy
Answer: A
Subject: Transplantation
Question: Question 5822
Which ONE of the following is a risk factor for post-transplantation malignancy?
1. Younger age
2. Female sex
3. Use of two or more immunosuppressive agents
4. Black race
Answer: C
Subject: Transplantation

A 48-year-old woman has ESRD due to FSGS. She is wait-listed for deceased donor transplantation and is seen for a routine re-evaluation. Her BMI is 36 kg/m2. She expresses concern about her risk for the development of diabetes mellitus after transplantation and asks about steroid elimination (no corticosteroids after an intraoperative bolus)..
Question: Which ONE of the following should you tell her about steroid elimination after the intra-operative steroid bolus following transplantation and the risk of diabetes mellitus?
1. It will increase her risk of rejection
2. It will reduce her risk of becoming diabetic
3. It will adversely affect her risk of early graft failure and mortality
4. It will adversely affect her achieved eGFR
5. It will increase her risk of recurrent FSGS
Answer: A
Subject: Transplantation

A 49-year-old man with type 1 diabetes and ESRD is referred for kidney transplantation. He has hypertension, dyslipidemia, and no history of cardiovascular disease. His electrocardiogram shows mild left ventricular hypertrophy. A trans-thoracic echocardiogram reveals left ventricular hypertrophy and mild diastolic dysfunction with-out overt pulmonary hypertension..
Question: Which ONE of the following statements about pre-transplantation cardiovascular screening tests for this patient is most CORRECT?
1. Trial data clearly indicate the need for left and right heart catheterization
2. An exercise treadmill stress test is sufﬁcient to screen for asymptomatic coronary artery disease
3. Most transplantation programs submit trans-plantation candidates to a rigorous cardio-vascular evaluation, although the evidence basis for this approach is lacking
4. Cardiac positron emission tomography myocardial perfusion imaging has replaced the need for coronary angiography for such patients
Answer: C
Subject: Transplantation

A 63-year-old woman with IgA nephropathy is evaluated 2 weeks after receiving a preemptive deceased-donor kidney transplant. She has known hypertension and dyslipidemia. She has previously experienced myalgias while taking atorvastatin at a dose of 80 mg daily, prompting her to stop statin therapy about 1 month before transplantation. You discuss re-initiation of statin therapy. She asks about the potential impact of statin therapy on her outcomes..
Question: Which ONE of the following should you tell her about statin therapy and outcomes after kidney transplantation?
1. Statin therapy after transplantation is associated with improved survival after transplantation
2. Statin therapy after transplantation reduces the risk of major adverse cardiovascular events without affecting mortality
3. Statin therapy is ineffective after transplantation because of the impact of immunosuppression on lipid levels
4. There is no relationship between statin dose and outcomes after transplantation
Answer: A
Subject: Transplantation

A 47-year-old woman with ESRD due to IgA nephropathy is evaluated for kidney transplantation. She was previously treated with a 6-month course of corticosteroids and is concerned about her future risk of fracture. Her medications include lisinopril for hypertension and omeprazole for gastroesophageal reﬂux. Her laboratory studies show a serum parathyroid hormone level (PTH) of 172 pg/ml (reference range 12–88 pg/ml), an alkaline phosphatase level of 128 U/L (reference range 38–126 U/L), a 25-hydroxy-vitamin D level of 30 ng/ml, and a procollagen type-1 N-terminal propeptide level of 80 µg/L (reference range 16–96 µg/L). A dual energy x-ray absorptiometry scan shows normal bone density with a Z score of 2.0 and a T score of 1.2..
Question: Which ONE of this patient’s clinical parameters is associated with the GREATEST risk of fracture after transplantation?
1. The procollagen type-1 N-terminal propeptide level
2. Omeprazole therapy
3. The serum PTH level
4. The results of dual energy x-ray absorptiometry
5. The serum alkaline phosphatase level
Answer: B
Subject: Transplantation

An endocrinologist consults with you about your patient, a 62-year-old man who received a living donor kidney transplant 8 months ago who has persistent hyperparathyroidism. Recent laboratory studies showed a serum creatinine level of 1.2 mg/dl, calcium of 11.8 mg/dl, phosphorus of 1.7 mg/dl, PTH of 387 pg/ml, and a 25-hydroxy-vitamin D level of 32 ng/ml. A nonobstructing stone measuring 8 mm is seen on an ultrasonogram of the transplanted kidney. You and your endocrine colleague discuss the relative merits of sub-total parathyroidectomy versus cinacalcet therapy..
Question: Which ONE of the following should you tell your endocrine colleague about subtotal parathyroidectomy versus therapy with cinacalcet in renal transplant recipients?
1. Cinacalcet is more effective in increasing serum phosphorus levels than subtotal parathyroidectomy
2. Cinacalcet is more effective than subtotal parathyroidectomy in lowering PTH levels
3. Subtotal parathyroidectomy more effectively controls hypercalcemia when compared with cinacalcet
4. Cinacalcet is associated with a higher risk of hypocalcemia than subtotal parathyroidectomy
5. Subtotal parathyroidectomy is associated with improved patient survival compared with cinacalcet
Answer: C
Subject: Transplantation
Question: Question 5828
Which ONE of the following statements about the treatment of post-transplantation osteoporosis is most CORRECT?
1. Raloxifene improves bone mineral density in transplant recipients
2. Teriparatide reduces the risk of fracture after kidney transplantation
3. Denosumab is a safe and effective treatment for osteoporosis after transplantation
4. Bisphosphonate therapy is associated with improvements in bone mineral densitometry scores after transplantation
5. Vitamin D analogues clearly reduce the risk of fracture after transplantation
Answer: D
Subject: Transplantation

A 58-year-old woman with ESRD of unknown cause is referred for transplantation. She was recently found to have HCV infection (genotype 1a). The HCV RNA PCR level is 200,000 IU/ml. She has no evidence of cirrhosis. She asks whether she should be treated for hepatitis C before or after kidney transplantation..
Question: Which ONE of the following should you tell her about the treatment of hepatitis C in relation to kidney transplantation?
1. Hepatitis C should be treated before trans-plantation to minimize the risk of liver failure after transplantation
2. Hepatitis C treatment should be deferred until after transplantation of a hepatitis C + graft to reduce waiting time
3. Hepatitis C should be treated before trans-plantation to abrogate the risk of coinfection with a different strain of virus that may pose the risk of drug resistance
4. Hepatitis C should be treated before trans-plantation to minimize the risk of rejection
5. Regardless of whether hepatitis C is treated before or after transplantation, she is at risk of anemia because of the requirement for ribavirin therapy
Answer: B
Subject: Transplantation

A 39-year-old man with ESRD of unknown cause is referred for transplantation. He has HIV infection that is well controlled by highly active antiretroviral therapy. His CD4 count is normal. He has never had an AIDS-deﬁning diagnosis, and his CD4 count is  > 400 cells/µL. He asks about the impact of his HIV infection on his outcomes after transplantation..
Question: Which ONE of the following should you tell him about outcomes following kidney transplantation in people with well controlled HIV infection?
1. HIV positive patients have a higher risk of graft loss than HIV2 recipients
2. HIV positive  kidney transplant recipients have the same risk of mortality as HIV2 recipients
3. Concurrent use of protease inhibitors with tacrolimus poses an increased risk of nephrotoxicity without affecting the risk of graft failure
4. The risk of opportunistic infections is higher in HIV positive   kidney transplant recipients compared with HIV negative recipients
5. Concurrent HCV positivity will have no additional impact on outcome after transplantation
Answer: A
Subject: Transplantation
Question: Question 5831
Which ONE of the following statements about therapy for inhibition of mammalian target of rapamycin is most CORRECT?
1. It is associated with a lower risk of BK virus allograft nephropathy after kidney transplantation compared with calcineurin inhibitor therapy
2. It is associated with a lower risk of CMV infection after kidney transplantation com-pared with calcineurin inhibitor therapy
3. It is associated with improved graft survival after transplantation compared with tacrolimus therapy
4. It is associated with a lower risk of acute rejection compared with tacrolimus-based immunotherapy
5. It has no impact on wound healing
Answer: B
Subject: Transplantation

A 29-year-old woman with type 1 diabetes mellitus since age 2 years and stage G5 CKD is referred for transplantation. In addition to mild uremic symptoms, she has longstanding brittle diabetes mellitus with hypoglycemic unawareness. She asks about pancreas transplantation. Her brother has volunteered to be her living donor..
Question: Which ONE of the following should you tell her about pancreas transplantation?
1. Living donor kidney transplantation followed by a pancreas after kidney transplantation will likely provide the best long-term renal outcomes
2. Pancreas transplantation alone is associated with inferior outcomes compared with simultaneous kidney pancreas transplantation
3. Pancreas transplantation is associated with a lower risk of infection compared with kidney transplantation alone
4. Her risk of BK viremia will be lower if she receives a pancreas in addition to a kidney transplant
Answer: A
Subject: Transplantation

A 48-year-old man with ESRD of unknown cause is referred for transplantation. He was found to have blood and protein in his urine when he underwent a medical evaluation for the Navy and was consequently denied entry at age 18. For the past 20 years, he has been intermittently treated for hypertension, although his adherence to medical care has been sporadic. He is now highly motivated to receive a transplant. He initiated hemodialysis about 5 months ago after acutely presenting with uremia. His evaluation at that time showed that he had atrophic kidneys and a urine protein-to-creatinine of 3200 mg/g..
Question: Which ONE of the following statements about this patient’s risk for recurrent glomerular disease after transplantation is most CORRECT?
1. Kidney biopsy should be performed now to help assess his risk for recurrent glomerular disease
2. He should be told that approximately 15% of transplants fail because of recurrent glomerular disease
3. His risk of recurrent glomerular disease will be lower if he receives a living related compared with a deceased donor transplant
4. His allograft prognosis will be worse if he receives a living donor versus a deceased donor transplant because of the risk of recurrent glomerular disease
Answer: B
Subject: Hypertension

You receive a request to evaluate a 22-year-old college student who was found to have a BP of 158/99 mmHg at the dentist’s oﬃce. Because of her ﬁnal examination schedule, she cannot come to your oﬃce to be seen for another month..
Question: What is the next best step in the management of this patient?
1. Initiate amlodipine 5 mg daily so that you can assess if she needs additional therapy when she presents for her visit
2. Recommend that she obtain kiosk-based BP measurements at her local supermarket until she is able to come into the clinic to be evaluated
3. Recommend that she purchase a validated home BP monitor and provide her with guidance on appropriate measurement technique
4. Initiate losartan-hydrochlorothiazide 25 to 12.5 mg daily so that you can assess if she needs additional therapy when she presents for her visit
Answer: C
Subject: Hypertension

You have been following a 68-year-old man for several years who has a history of stable proteinuric CKD Stage IV, hypertension, heart failure with preserved ejection fraction, and hypothyroidism. His BP has been at or below his goal in the oﬃce for the past 6 years on valsartan 320 mg daily, chlorthalidone 25 mg daily, and amlodipine 5 mg daily. He presents to clinic noting that he recently purchased a home BP monitor, which has been showing BPs consistently 10 to 15 mmHg above his goal..
Question: Which of the following is the best response to this patient’s home readings?
1. Ignore the readings, given that his BPs are consistently well controlled in the oﬃce
2. Suggest that he stop monitoring his BP at home because you suspect he is not able to use appropriate measurement technique
3. Add spironolactone for improved BP control because of the presence of masked uncontrolled hypertension
4. Recommend 24-hour ambulatory BP monitoring (ABPM) to conﬁrm the presence of masked uncontrolled hypertension
Answer: D
Subject: Hypertension

A new patient presents for evaluation of asymptomatic labile BPs at home ranging from the 80s/30s mmHg to 190s/110s mmHg using his new cuﬄess watch, which was advertised by his favorite technology magazine as being the top new device on the market for monitoring BP..
Question: Which of the following is the best approach to this patient’s BP measurement?
1. Recommend that he undergo 24-hour ABPM
2. Encourage him to continue to monitor his BP at home using this device because BP monitors cannot be marketed unless they are accurate
3. Recommend that he undergo evaluation for autonomic dysfunction
4. Recommend that he obtain a kiosk-based BP measurement at his local supermarket until he is able to come into the clinic to be evaluated
Answer: A