SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Chronic Kidney Disease and Progression
A 65-year-man with morbid obesity, type 2 diabetes mellitus, and Barrett esophagus is re-ferred for evaluation and management of stage G4:A2 CKD. His medications are chlorthalidone 25 mg daily, losartan 100 mg daily, amlodipine 10 mg daily, and omeprazole 40 mg daily. His resting sitting BP is 125/68 mmHg. Laboratory studies show an eGFR of 28 ml/min per 1.73 m2 and a urine albumin-to-creatinine ratio of 450 mg/g. The urine sediment shows a few hyalofatty casts but is otherwise unremarkable. His eGFR has not changed over the past 12 months. He asks if anything can be done to slow his CKD pro-gression. He read a recent press release about proton pump inhibitors and CKD progression, and he asks if he should stop or change this medication..
Question: Which ONE of the following should you tell him about proton pump inhibitors in the context of his CKD?
A.        His proton pump inhibitor should be stop-ped because it is a major risk factor for CKD progression
B.        The proton pump inhibitor should be stop-ped because it increases the risk of hyper-magnesemia in advanced CKD
C.        The proton pump inhibitor should not be discontinued if the medication is required to treat his Barrett esophagus and there is no clinical evidence of harm
D.        Studies have shown strong and consistent associations of proton pump inhibitors with CKD risk and progression
Answer: C
Subject: Chronic Kidney Disease and Progression
You are seeing a 65-year-old man with a newly hired advanced-practice provider in your practi-ce’s CKD clinic. The patient has stage G4:A2 CKD. He has no complaints and denies fatigue, shortness of breath, or chest pain. His medications include chlorthalidone, losartan, pravastatin, and aspirin. The BP is 128/67 mmHg. The remainder of the physical examination is unremarkable. Laboratory studies reveal an eGFR of 22 ml/min per 1.73 m2, which is stable when compared with the eGFR measured 4 months ago. The urine albumin-to-creatinine ratio is 45 mg/g. The hemo-globin is 8.9 g/dl. The iron saturation is 32%. The advanced-practice provider asks about adding an erythropoiesis-stimulating agent..
Question: Which ONE of the following should you tell the advanced-practice provider regarding initiation of erythropoiesis-stimulating agents in this patient?
A.        An erythropoiesis-stimulating agent will not slow his CKD progression
B.        An erythropoiesis-stimulating agent will not improve his functionality and exercise tolerance
C.        Erythropoiesis-stimulating agent use will not reduce his need for blood transfusions
D.        An erythropoiesis-stimulating agent should be held when hemoglobin levels exceed 10.0 g/dl
Answer: A
Subject: Chronic Kidney Disease and Progression
A 22-year-old man with a remote history of acute kidney disease during childhood is referred to you for evaluation. He has no hypertension or diabetes mellitus and takes no prescribed or over-the-counter medications. His past medical history is notable for a hospitalization when he was a toddler for severe pneumonia, which was complicated by “a kidney problem,” and he thinks he may have received dialysis a few times. He has otherwise been healthy, but he does not have any more information on his past illness. The eGFR is 98 ml/min per 1.73 m2 by the CKD-Epi equation and the urine albumin-to-creatinine ratio is 17 mg/g..
Question: Which ONE of the following should you tell him regarding his lifetime risk of ESRD?
A.        His lifetime risk of ESRD may be increased by more than fourfold because of his child-hood history of kidney injury
B.        His risk is not increased because his serum creatinine is now normal
C.        The childhood illness is not relevant for this patient
D.        Adults with childhood CKD have a higher risk of ESRD than do adults without a childhood CKD history, but initiation of dialysis in adults with a history of childhood CKD occurs at a later age
Answer: A
Subject: Chronic Kidney Disease and Progression
A 31-year-old man from Costa Rica is referred to you by a colleague for evaluation of an elevated serum creatinine level. He has no history of diabetes mellitus or hypertension. His body mass index is 17.9 kg/m2, and his BP is 122/82 mmHg. The remainder of the examination is normal. Laboratory studies show a serum creatinine of 1.7 mg/dl and a urine albumin-to-creatinine ratio of 37 mg/g. Serum complement levels are nor-mal. The urine sediment shows a few ﬁne granular casts. You suspect the patient may have Mesoamerican nephropathy..
Question: Which ONE of the following biopsy ﬁndings is MOST consistent with the diagnosis of Mesoamerican nephropathy?
A.        Tubulointerstitial nephritis with inﬁltrates predominantly of T lymphocytes
B.        Mesangial and subendothelial immune deposits
C.        Collapse and sclerosis of the entire glomer-ular tuft
D.        Hypercellular crescent formation with ﬁbri-noid necrosis
Answer: A
Subject: Chronic Kidney Disease and Progression
A 58-year-old man with stage G3a:A3 CKD secondary to diabetic nephropathy is evaluated during a routine follow-up visit. His medications are lisinopril 40 mg once daily, atorvastatin 40 mg once daily, and metformin 500 mg twice daily. On physical examination, the BP is 128/85 mmHg. The remainder of the examination is unremarkable. Home BP readings average 128/80 mmHg. Laboratory studies show a hemo-globin A1c of 7.1% and an eGFR of 48 ml/min per 1.73 m2. The urine albumin-to-creatinine ratio is 420 mg/g..
Question: The addition of which ONE of the following interventions is the MOST likely to delay progression of his CKD?
A.        Losartan
B.        Atrasentan
C.        An SGLT-2 inhibitor
D.        Liraglutide
Answer: C
Subject: Chronic Kidney Disease and Progression
A 57-year-old man with type 2 diabetes and hypertension is evaluated in follow-up care for stage G3a:A3 CKD. He was recently prescribed empagliﬂozin by his primary care physician after his hemoglobin A1c level was found to be elevated at 7.9%. He is asymptomatic. The BP is 128/82 mmHg. He has no edema. Laboratory data show an eGFR of 54 ml/min per 1.73 m2 and UACR of 350 mg/g. He is concerned about the adverse effects of empagliﬂozin, especially in the setting of preexisting kidney disease..
Question: Which ONE of the following should you tell him about potential adverse events related to treatment with sodium glucose cotransporter-2 (SGLT-2) inhibitors?
A.        Amputation has been reported with all SGLT-2 inhibitors
B.        The risk of genital infections is higher
C.        There is no risk of acute kidney injury
D.        The risk of hypoglycemia is increased
Answer: B
Subject: Chronic Kidney Disease and Progression
Question: Question 2970:
Which ONE of the following BEST describes current evidence regarding the use of hypo-glycemic agents in CKD?
A.        Dulaglutide is superior in reducing CKD progression and albuminuria compared with insulin glargine
B.        Incretin-based therapies delay the progres-sion of CKD
C.        Only individuals with stage G4 CKD de-rive cardiovascular beneﬁt from SGLT-2 inhibitors
D.        The risk of metformin-associated lactic acidosis is dependent on the stage of CKD
Answer: D
Subject: Chronic Kidney Disease and Progression
An 81-year-old man with stage G4:A3 CKD is evaluated during a routine follow-up visit. He has long-standing hypertension, type 2 diabetes mel-litus, and hyperlipidemia. He is asymptomatic. On physical examination, the BP is 132/84 mmHg. The pulse is found to be irregularly irregular, with a rate of 74/min. The remainder of the physical examination is normal. An elec-trocardiogram shows atrial ﬁbrillation, which was not noted in a previous electrocardiogram ob-tained 2 weeks ago. Laboratory studies show a serum creatinine level of 2.6 mg/dl and a urine albumin-to-creatinine ratio of 680 mg/g. You discuss the beneﬁts and risks of anticoagulation..
Question: Which ONE of the following should you tell him regarding the potential beneﬁts and risks he will derive from anticoagulation for atrial ﬁbrillation?
A.        It will not increase his risk of bleeding
B.        It will lower his risk of ischemic stroke
C.        It will lower his mortality risk
D.        Direct oral anticoagulants, but not warfarin, have been proved to improve clinical out-comes in stage 4 CKD
Answer: C
Subject: Chronic Kidney Disease and Progression
A 66-year-old woman with a history of atrial ﬁbrillation, hypertension, hyperlipidemia, gastro-esophageal reﬂux disease, and depression is re-ferred for evaluation of CKD. Her medications include amiodarone, ﬂuoxetine, furosemide, pan-toprazole, and atorvastatin. On physical exami-nation, the BP is 116/78 mmHg. The pulse is irregularly irregular. There is trace pedal edema. The remainder of the examination is normal. Laboratory studies show a hemoglobin of 12.1 g/dl, sodium of 142 mEq/L, potassium of 3.6 mEq/L, chloride of 102 mEq/L, total CO2 of 29 mmol/L, BUN of 63 mg/dl, and creatinine of 1.5 mg/dl (eGFR 35 ml/min per 1.73 m2). An electrocardiogram shows normal sinus rhythm with a prolonged QTc interval of 520 milliseconds..
Question: Which ONE of her medications is LEAST likely to be directly contributing to the in-creased QTc interval?
A.        Furosemide
B.        Pantoprazole
C.        Citalopram
D.        Amiodarone
Answer: B
Subject: Chronic Kidney Disease and Progression
A 58-year-old African American woman with stage G4:A3 CKD is evaluated during a routine follow-up visit. Her primary care physician re-cently diagnosed atrial ﬁbrillation and started anticoagulation with warfarin. An echocardiogram showed a left ventricular ejection fraction of 50%, an elevated left ventricular mass index, increased relative wall thickness, elevated pulmonary artery pressure, and increased left atrial diameter..
Question: Which ONE of the following ﬁndings on her echocardiogram is associated with either a >30% decline in eGFR or ESRD?
A.        Increased pulmonary artery systolic pressure
B.        The left ventricular ejection fraction of 50%
C.        Increased left ventricular mass index
D.        Increased relative wall thickness
Answer: C
Subject: Chronic Kidney Disease and Progression
A 42-year-old woman with stage G3a:A2 CKD, morbid obesity, type 2 diabetes mellitus, and hypertension is seen in consultation before planned bariatric surgery. Her eGFR is 59 ml/min per 1.73 m2. The urine albumin-tocreatinine ratio is 190 mg/g. She asks about the potential beneﬁts and risks of undergoing bariatric surgery..
Question: Which ONE of the following should you tell her about her the beneﬁts and risks of bariatric surgery?
A.        It is not associated with an increased risk of acute kidney injury
B.        It reduces the risk of incident CKD and ESRD
C.        It does not have an impact on urinary protein excretion
D.        It has no impact on resolution or reduction of hypertension
Answer: B
Subject: Chronic Kidney Disease and Progression
A 56-year-old man with hypertension is seen in consultation for CKD. His eGFR is 44 ml/min per 1.73 m2, decreased from 50 ml/min per 1.73 m2 3 years ago. On physical examination, the BP is 118/70 mmHg, and the body mass index is 34 kg/m2. The remainder of the examination is normal. His most recent laboratory studies show a total cholesterol of 188 mg/dl, low-density lipoprotein-cholesterol of 110 mg/dl, calcium of 9.8 mg/dl, phosphorus of 3.6 mg/dl, hemoglobin A1c of 5.2%, and high-sensitivity C-reactive protein of 4.2 mg/L (reference range ,3 mg/L)..
Question: Which ONE of the following interventions has the BEST potential to improve his cardiovas-cular and kidney health?
A.        Diet and exercise
B.        Lorcaserin
C.        Bariatric surgery
D.        Further BP reduction
Answer: A
Subject: Chronic Kidney Disease and Progression
A 63-year-old woman with a history of hyper-tension, obesity, and depression is seen in follow-up care for stage G4:A2 CKD. She was recently found to have iron deﬁciency anemia. The results of colonoscopy and esophagogastroduodeno-scopy were normal. Laboratory studies show a hemoglobin of 8.6 g/dl and a transferrin satu-ration of 10%. You discuss the risks and beneﬁts of available iron supplements..
Question: Which ONE of the following should you tell her?
A.        The 1-year risk of infections and cardiac-related adverse events is increased with intravenous ferric carboxymaltose com-pared with oral iron therapy
B.        Oral iron supplementation is unlikely to improve her hemoglobin level
C.        Oral iron supplementation with ferric citrate leads to higher rates of adverse events when compared with placebo
D.        Compared with oral iron therapy, the in-cidence of adverse events is similar with intravenous ferric carboxymaltose
Answer: D
Subject: Chronic Kidney Disease and Progression
You are asked to see a 70-year-old man for the management of stage G3b:A3 CKD and associ-ated complications. He has type 2 diabetes mellitus, hypertension, and coronary artery dis-ease, for which he underwent coronary artery bypass surgery 5 years ago. A recent echocardio-gram shows a left ventricular ejection fraction of 35%. An electrocardiogram shows normal sinus rhythm with normal intervals (QRS in-terval 110 milliseconds). Laboratory studies show a serum sodium of 137 mEq/L, potassium of 3.8 mEq/L, chloride of 105 mEq/L, total CO2 of 21 mmol/L, BUN of 34 mg/dl, creatinine of 1.5 mg/dl, and an eGFR of 46 ml/min per 1.73 m2 (comparedwithaneGFRof48ml/minper 1.73 m2 1 year ago and 51 ml/min per 1.73 m2 2 years ago)..
Question: Which of ONE the following is MOST likely to improve his survival?
A.        Cardiac resynchronization therapy
B.        Placement of an implantable cardioverter deﬁbrillator
C.        Addition of mineralocorticoid receptor antagonis
D.        Addition of sodium bicarbonate targeting a total CO2 level of 23 to 28 mmol/L
Answer: C
Subject: Chronic Kidney Disease and Progression
A 57-year-old man with type 2 diabetes, hyper-tension, peripheral artery disease, and stage G2:A3 CKD is evaluated in follow-up care. His medications include lisinopril, metformin, cana-gliﬂozin, pravastatin, and aspirin. The physical examination reveals evidence of diabetic retinop-athy and neuropathy. The eGFR, using the CKD-EPI creatinine-based equation, has consistently ranged from 70 to 75 ml/min per 1.73 m2 over the past year. The urine albumin-to-creatinine ratio is 650 mg/g..
Question: Which ONE of the following factors is LEAST likely to place him at increased risk for amputation?
A.        The current level of eGFR
B.        Increased albuminuria
C.        The presence of neuropathy
D.        Canagliﬂozin therapy
Answer: A
Subject: Chronic Kidney Disease and Progression
You have been asked by your colleagues to review new methods of cardiovascular risk prediction in your CKD practice. You review the literature and present your ﬁndings..
Question: Which ONE of the following should you report to your colleagues?
A.        Coronary ﬂow reserve declines with kidney disease progression, and cardiovascular risk in patients with low coronary ﬂow reserve is ampliﬁed in those with advanced CKD
B.        Elevations in N-terminal pro–brain natriuretic peptide (NT-proBNP) are not associated with an increased risk of subsequent cardiac events
C.        The addition of echocardiographic variables to clinical variables and NT-proBNP improves cardiovascular risk prediction
D.        Coronary artery calciﬁcation in CKD is associated with an increased risk of adverse cardiovascular events
Answer: D
Subject: Chronic Kidney Disease and Progression
An 82-year-old man with stage G4:A2 CKD is brought in by his family for evaluation of CKD. A recent MRI without gadolinium contrast material performed during an evaluation after a fall showed abnormal white matter volume. His family is interested in understanding the signiﬁcance of these ﬁndings and its relationship to kidney function..
Question: Which ONE of the following statements about cognitive function and MRI data in CKD is CORRECT?
A.        Albuminuria and lower eGFR are associated with worse global cognitive function
B.        Both higher UACR and lower eGFR are associated with abnormal white matter volume
C.        Both higher UACR and lower eGFR are associated with higher grey matter volume
D.        Increased albuminuria is not associated with poorer processing speed and working memory
Answer: B
Subject: Transplantation

A 52-year-old woman with ESRD due to IgA nephropathy has been on the transplantation wait-ing list for 2 years. She has tolerated peritoneal dialysis well without complications and has not had any recent hospitalizations. Her blood type is B, and the calculated panel of reactive antibodies (cPRA) is 80% with 2 years of dialysis time. The expected waiting times in her region are 2 years, 3 years, 4 years, and 4.5 years for blood types AB, A, B, and O, respectively. The waiting time for a high kidney donor proﬁle index (KDPI) (> 85%) donor is approximately 6 to 12 months shorter. She asks about options that could reduce her waiting time. She declines consent for Public Health Service-Increased Risk (PHS-IR) donor kidney or a hepatitis C–positive kidney..
Question: Which ONE of the following is the BEST available treatment option to reduce her waiting time?
1. Consent for high KDPI kidney offers
2. Testing for anti-A antibody titers to assess suitability for non-A1 donor kidneys
3. Desensitization with rituximab and intravenous immunoglobulin (IVIG)
4. Immunoadsorption therapy to remove lymphocytotoxic antibodies
Answer: B
Subject: Transplantation

A 69-year-old woman with ESRD due to type 2 diabetes mellitus is to receive a deceased-donor transplant after 4 years on the transplantation waiting list. Shortly after placement on the waiting list, she had a 1-week hospitalization for catheter-associated sepsis. Later that year, she underwent emergent cholecystectomy and spent 8 days in the hospital. She has had periods of “inactive status” while awaiting transplantation because of deconditioning, including a hospital stay for a hip fracture after a fall within the past year. She is unable to work, lives at home, and cares for most of her personal needs requiring only occasional assistance, yielding a Karnofsky score of 60. A recent timed “get up and go” test was 15 seconds (11–20 seconds is consistent with frail elderly or disabled status). Her cardiovascular test results are satisfactory, and she is otherwise considered an acceptable candidate for transplantation..
Question: Which ONE of this patient’s characteristics is associated with INCREASED mortality after transplantation?
1. Hospital admissions during the ﬁrst year of waitlisting
2. A serious fall in the year before transplantation
3. A Karnofsky score of 60
4. A “timed get up and go” test result indicative of frailty
Answer: A
Subject: Transplantation

A 71-year-old man with ESRD due to diabetic nephropathy maintained on peritoneal dialysis for the past 2 years is evaluated for kidney trans-plantation. He has coronary artery disease that required three-vessel coronary bypass surgery 5 years ago. His left ventricular function is normal. A recent stress myocardial perfusion scan revealed no ischemia. He does not have peripheral vascular disease and is not frail on formal assessment. He is approved for kidney transplantation and is placed on the active waitlist. His expected posttransplantation survival (EPTS) score is 93. He cannot identify potential living donors. In his region, he would be predicted to receive a KDPI 35-85 kidney with 4 years of dialysis time and a KPDI  > 85 kidney with 3 years of dialysis time..
Question: When considering his survival with or without transplantation and potential organ acceptance offers for him, which ONE of the following should you recommend?
1. He should not be consented for KDPI .85 kidneys because of the increased risk associated with high KDPI kidneys transplanted to individuals with high EPTS scores
2. He should not be placed on the waiting list because he is not expected to have a survival beneﬁt from transplantation
3. He should be encouraged to consent for KDPI > 85 kidneys because of the increased survival associated with high KDPI kidneys compared with remaining on the waitlist for a KDPI 35-85 kidney
4. He should be considered only for KDPI  > 85 kidneys, given his high EPTS
Answer: C
Subject: Transplantation

A 52-year-old man with autosomal dominant poly-cystic kidney disease and ESRD has been active on the kidney transplantation waitlist for 5 years. He receives a kidney offer and is informed “the kidney appears excellent” but is considered a PHS-IR donor. The patient contacts you and asks whether he should accept the organ..
Question: A discussion begins about the beneﬁts and risks of receiving a PHS-IR donor kidney versus continued waiting for a non–PHS-IR donor kidney
When considering the acceptance of a PHS-IR donor compared with continued waiting for a donor that is NOT at increased risk, which ONE of the following should you tell him?
1. There is no survival advantage in accepting the PHS-IR kidney versus accepting the next non-IR offer
2. It is likely that the PHS-IR kidney is of higher expected function/longevity than the next non-IR offer will be
3. The risk for hepatitis C virus (HCV) infection is about 5% and for HIV is about 1%
4. Although graft function is historically inferior from PHS-IR donors than from non-IR donors, this difference is now mitigated by newer antiviral treatments
Answer: B
Subject: Transplantation

A 67-year-old man with ESRD due to obstructive uropathy who initiated hemodialysis 3 months ago is placed on the transplantation waiting list. He has no identiﬁed living donors, and his waiting time for a deceased donor is estimated to be about 5 years. He wishes to explore all possible transplantation options, including consideration of an HCV-infected (HCV +/nucleic acid testing [NAT] + donor. He is seronegative for HCV..
Question: Which ONE of the following should you tell him regarding kidney transplantation with HCV1 donor kidneys?
1. If untreated, HCV Ab1/NAT2 kidney donors carry a risk of viral transmission that is > 90%
2. Direct-acting antiviral therapy for the clearance (cure) of HCV is less effective in the kidney transplantation population than in the general population
3. The median waiting time to transplantation is reduced to a similar extent for those who consent to receive a kidney from an HCV Ab + donor as those who consent to receive a high KDPI kidney
4. Transplantation of HCV Ab + /NAT + kidneys followed by direct-acting antiviral therapy is cost effective compared with continued waiting during dialysis and subsequent receipt of an HCV2 deceased-donor kidney
Answer: D
Subject: Transplantation

A 59-year-old woman wishes to donate her kidney to her niece, a 32-year-old woman with ESRD due to IgA nephropathy. She has no past medical or surgical history. Her BMI is 25 kg/m2, her blood pressure is 132/80 mmHg, and her measured GFR is 95 ml/min per 1.73 m2..
Question: Which ONE of the following INCREASES her risk of ESRD after donation?
1. Female sex
2. Relationship to the recipient
3. Age > 50 years
4. BMI 25 kg/m2
Answer: C
Subject: Transplantation

A deceased-donor kidney from a donor with anoxic brain injury and brain death is to be shipped from Virginia to Arizona for a patient with a cPRA of 98%. The expected cold ischemia time is 26 hours, increasing concern for delayed graft function once transplanted..
Question: Which ONE of the following interventions has been shown to REDUCE the risk of delayed graft function?
1. Hypothermic machine perfusion (HMP) of the explanted kidney
2. Dopamine infusion of the donor before procurement
3. Remote ischemic conditioning of the recipient (thigh occlusion)
4. Complement inhibition of the recipient at the time of transplant
Answer: A