SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 58-year-old hemodialysis patient with longstanding type 1 diabetes and hypertension and on the deceased donor waiting list for a kidney pancreas transplant has a lateral abdominal radiograph as part of evaluation for back pain..
Question: The radiologist reports “signiﬁcant abdominal aortic calciﬁcation of 12/24 using the Kauppila scoring method.”
Which of the following statements is the most accurate?
1. Abdominal aortic calciﬁcation is associated with increased cardiovascular risk and mortality, but this association is quickly lost after transplantation
2. Abdominal aortic calciﬁcation is associated with increased cardiovascular risk but has not been shown to associate with increased mortality
3. A low Kauppila score associates with a high cardiovascular risk
4. Abdominal aortic calciﬁcation has been associated with increased risk of cardiovascular events and increased mortality, which persists after transplantation
Answer: D
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 75-year-old man has ESKD from longstanding diabetes and hypertension and is receiving hemodialysis three times weekly, 4 hours. His dialysis prescription is as follows: 4 hours, optiﬂux 180 dialyzer, blood ﬂow rate 400 ml/min, dialysate ﬂow rate 800 ml/min. Dialysis bath includes: sodium 137 mEq/L, potassium 2 mEq/L, calcium 2.25 mEq/L, magnesium 1 mEq/L..
Question: Based on current data, which ONE of the following changes to dialysis regimen would improve the serum calciﬁcation propensity as measured by increased T50?
1. Change sodium to 135 mEq/L
2. Change potassium to 1 mEq/L
3. Change magnesium to 2 mg/dl
4. Increase dialysis time to target higher Kt/V
Answer: C
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

You have been following up a 59-year-old man with alcohol use disorder, chronic pancreatitis with malabsorption, diabetes, and ESRD who is receiving hemodialysis. He commonly misses dialysis because of transportation issues. He frequently skips medications because of ﬁnancial constraints. He has widespread vascular calciﬁcation on imaging..
Question: Which of the following is least likely to prevent or delay progression of vascular calciﬁcation?
1. Magnesium supplement
2. Vitamin K supplement
3. Calcium-containing phosphate binder
4. Calcimimetic agents
Answer: C
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 79-year-old woman with ESRD secondary to diabetes and hypertension fractured her hip while ambulating to a chair after dialysis. She receives dialysis three times weekly. Her most recent PTH is 89 mg/dl, phosphorus is 4.9 md/dl (reference range 1–9 mg/dl), and calcium is 8.8 mg/dl..
Question: Which statement below is incorrect?
1. In her age group, the risk of fracture is higher for ESRD compared with non-ESRD patients
2. The mortality risk for ESRD patients is higher after the fracture compared with mortality risk in nonESRD patients after fracture
3. Factors that increase the fracture risk of ESRD patients include age and CKD with mineral and bone disorder but not osteoporosis
4. She is more likely to have a prolonged hospitalization after the fracture
Answer: C
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 61-year-old woman has stage 3 CKD related to class 4 lupus nephritis treated successfully with Cytoxan and glucocorticoids when she was 30 years old. She has mild hypertension and is taking lisinopril 20 mg daily, atorvastatin, and a multivitamin. PTH, phosphorus, and alkaline phosphatase have always been in normal range. She has never been screened for osteoporosis because her nephrologist told her the results of common screening methods would be diﬃcult to interpret. Her current primary care physician asks you for advice regarding screening..
Question: Which of the following statements is most accurate?
1. There is little utility to screening by dual energy x-ray absorptiometry (DXA) because she likely has renal osteodystrophy, and DXA would not be suﬃciently predictive of fracture risk
2. There is little utility to screening because the treatments for osteoporosis are contraindicated by her reduced eGFR
3. Bone density screening would not be helpful because patients with lupus will have too much arthritis to get accurate density measurements
4. She should be screened by DXA every 12 to 24 months
Answer: D
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 72-year-old man has stage 4 CKD related to renovascular disease. He has coronary artery disease and has had a ST-elevation myocardial infarction, has undergone multiple angioplasties, has peripheral vascular disease, and has severe chronic obstructive pulmonary disease (COPD). He has been taking glucocorticoids for years for COPD. He has had several fractures related to falls and also has a nontraumatic vertebral fracture. He has been taking calcitriol for many years, but this was stopped when his PTH was noted to be < 100 pg/ml. Follow-up laboratory studies after vitamin D receptor activators was stopped show a low bone-speciﬁc alkaline phosphatase and PTH 120 pg/ml. Vitamin D levels are normal. Phosphorus is normal, and he is not using phosphate binders. Calcium is within normal range at 9.8 mg/dl..
Question: Which of the following agents could be used for his osteoporosis?
1. Pamidronate
2. Denosumab
3. Teriparetide
4. Romosozumab
Answer: C
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 60-year-old woman with stage 5 CKD and an eGFR 12 ml/min per 1.73 m2 is planned for hemodialysis and is noted to have osteoporosis on a routine DXA with a left femoral neck T score of −2.8. Her medical history. includes diabetes, obesity, hypertension, and a 20-pack/year smoking history, Her phosphate is 4.6 mg/dL, PTH is 530 pg/mL, bone-speciﬁc alkaline phosphatase is high, and vitamin D and calcium are normal..
Question: Which of the following agents is best for her osteoporosis?
1. Alendronate
2. Denosumab
3. Teriparetide
4. Abaloparatide
Answer: B
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 66-year-old woman with ESRD treated with maintenance hemodialysis is evaluated for severely painful induration of her anterior abdominal wall. She has chronic atrial ﬁbrillation treated with metoprolol and warfarin. Skin biopsy of an indurated lesion showed arteriolar calciﬁcation and thrombosis of subcutaneous adipose tissue. Fine stippled calciﬁcation was noted surrounding the perieccrine glands..
Question: Which ONE of the following statements most correctly describes this patient’s prognosis?
1. The presence of arteriolar calciﬁcation suggests advanced lesion stage and worse prognosis
2. The presence of arteriolar thrombosis indicates advanced lesion stage and worse prognosis
3. The 1-year mortality rate for patients with this condition is < 10%
4. The location of skin lesions inﬂuences prognosis
5. Ulcerated lesions have a similar prognosis to nonulcerated lesions
Answer: D
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 52-year-old white woman with ESRD secondary to diabetes mellitus treated with long-term ambulatory peritoneal hemodialysis receives a diagnosis of calciﬁc uremic arteriolopathy. The bilateral skin lesions are on her thighs and are severely painful. She has a history of subtotal parathyroidectomy performed many years ago. Her laboratory data include serum calcium 7.8 mg/dL, serum phosphate 6.4 mg/dL, serum PTH 27 pg/ml, and serum albumin 3.2 g/dL. Her current medications include calcium carbonate and calcitriol..
Question: In addition to discontinuing calcium carbonate and calcitriol, which ONE of the following is the most appropriate treatment of mineral bone abnormalities in this patient?
1. Add cinacalcet
2. Urgent surgical parathyroidectomy
3. Add aluminum hydroxide
4. Add sevelamer
Answer: D
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 59-year-old woman is referred for evaluation of recurrent stones sustained over the past 15 years. She has a 10-year history of diabetes, hypertension, and hypercholesterolemia, treated with metformin, lisinopril, and atorvastatin. She describes a steady increase in weight since her last pregnancy 30 years ago. She works as a computer programmer and notes little to no exercise except for walking from her car to her oﬃce. She tries to drink ﬂuids during the day but notes that she often leaves a bottle close to full at the end of the day. Her body mass index (BMI) is 33, with a waist circumference of 90 cm; her BP at home is 140/82 mmHg..
Question: Which of the following does not contribute to her risk of stone recurrence?
1. Insuﬃcient urine volume
2. Physical inactivity
3. High BMI
4. Diabetes
Answer: B
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 24-year-old man presents to an emergency department with sudden-onset left ﬂank pain, nausea, and vomiting after spending 4 days rafting on the Colorado River in July. He hasahistoryofkidneystones2yearsand4years ago,both evaluated with computed tomography (CT) urograms but not requiring intervention. Since that time he believes he has passed multiple small stones that required no intervention. His BP is 145/85 mmHg, and his heart rate is 110 beats/min. He is afebrile . He is extremely uncomfortable, but the results of abdominal examination are benign. Laboratory analysis shows creatinine 1.0 mg/dl and normal compre-hensive medical panel results. The results of a complete blood count are normal, with no leukocytosis. Urinalysis shows 3+ heme and no protein. Pain is adequately relieved with intravenous ketorolac..
Question: What is the best initial imaging test?
1. CT scan with intravenous contrast material
2. Radiograph of abdomen (kidneys, ureters, bladder)
3. CT urogram
4. Renal ultrasonography
Answer: D
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 48-year-old woman is referred for evaluation of recurrent nephrolithiasis. She has a history of recurrent stones since age 18 years, which she addresses with copious ﬂuid intake. A CT scan performed to evaluate hematuria shows “possible” medullary sponge kidney. Her medical history is otherwise remarkable for osteopenia detected by screening DXA scan..
Question: Which of the following is the most likely abnormality detected on 24-hour urine metabolic study?
1. High calcium
2. Low urine pH
3. High uric acid
4. High cystine
Answer: A
Subject: Disorders of Divalent Ions, Renal Bone Disease and Nephrolithiasis

A 45-year-old woman is referred for evaluation of recurrent stones. Her BMI is 45. She has diabetes and hypertension. She states that she is considering bariatric surgery for weight loss but is concerned because she heard that it will increase her risk of stones, even though she had previously been told that obesity was part of the reason for her prior stone risk..
Question: Which of the following is true regarding bariatric surgery?
1. Because the stones are calcium oxalate, the risk can be minimized by restricting dietary calcium and oxalate
2. The risk of stones related to bariatric surgery is lower than the risk conferred by obesity
3. The risk conferred by bariatric surgery can be minimized by restricting dietary fat, increasing dietary calcium or taking a calcium supplement with meals, and maintaining high urinary volume of > 2.5 L/d
4. The risk of stones is the same in all types of bariatric surgery
Answer: C
Subject: End-Stage Kidney Disease

A 69-year-old woman has ESKD related to longstanding diabetes and hypertension. She has paroxysmal atrial ﬁbrillation, coronary artery disease, and severe left ventricular hypertrophy by echocardiography. Dialysis regimen is 4.0 hours, three times weekly. Kt/Vurea is 1.5 per session, usual weight gain is 3 to 4 L. Predialysis laboratory values consistently demonstrated [K] 6.5 to 7.0 mEq/L, [Na] 125 to 129 mEq/L, [HCO3] 18 to 24 mEq/L [Cl] 99 to 105, [phosphorus] 7 to 8 mg/dl. She dialyzes with an arteriovenous ﬁstula with Qb approximately 400 ml/min. Venous pressure is 100 mmHg. She shows up for every treatment but commonly signs off early because of back pain after sitting in the chair for too long. She lives alone and tries to eat “healthy for her heart.” Dietician has discussed diet many times..
Question: Which of the following is the best management strategy for her hyperkalemia?
1. Continue dialysate [K] 2 mEq/L, reinforce dietary restriction, check for recirculation, add if these measures do not yield a decrease in the serum [K], add a potassium-binding resin on non-dialysis days
2. Increase dialysis time to 4.5 hours, continue dialysate [K] 2mEq/L
3. Dietary restriction, change dialysate to [K] 1 mEq/L
4. Dietary restriction and continue current regimen
Answer: A
Subject: End-Stage Kidney Disease

A 79-year-old man with ESKD related to hypertension and Apolipoprotein L1 gene is on dialysis: 3 days, 4 hours, QB/Qd 400 to 600 ml/min. Dialysate [Ca] is 2.5 mEq/L. Laboratory results show Kt/Vurea 1.4, serum [Ca] 8.4 mg/dl, [Phos] 5.9 mg/dl, parathyroid hormone 679 mg. His BP tends to drop 1 to 2 hours into treatment, which limits his ability to achieve dry weight..
Question: Changing his dialysate [Ca] to 2.75 would do which of the following?
1. Cause parathyroid hormone to increase further
2. Cause no change in total or ionized [Ca]
3. Decrease frequency of episodes of intradialytic hypotension
4. Have no effect on laboratory values or dialysis stability
Answer: C
Subject: End-Stage Kidney Disease

A 60-year-old woman with ESKD related to diabetes and received a living-related transplant that failed after 15 years. She is being evaluated for a second transplant from her partner. She is dialyzed three times weekly for 3.5 hours. Her estimated dry weight (EDW) is 64 kg, and she typically gains 4 to 5 L between dialysis sessions. Although she is generally hemodynamically stable and appears to tolerate aggressive ultraﬁltration (UF), the dialysis nurses are reluctant to increase her ultraﬁltration rate (UFR), so she leaves above her EDW. She has presented several times to the emergency department in pulmonary edema, always on the weekend. She continues to make urine..
Question: What is the best approach to prevent episodes of pulmonary edema?
1. Decrease her EDW to 62
2. Given that she tolerates it, double her UFR to make sure she always leaves at EDW
3. Add a loop diuretic on non-dialysis days and continue to limit her UFR during dialysis to < 13 ml/kg per h
Answer: C
Subject: End-Stage Kidney Disease

An 82-year-old woman has stage 5 CKD related to longstanding diabetes and hypertension plus NSAID use. She also has mild to moderate aortic stenosis and a mildly reduced ejection fraction, cerebral vascular disease having undergone carotid endarterectomy, and mild to moderate peripheral vascular disease that her vascular surgeon is closely following. She has poor manual dexterity and is perceived not to be a good candidate for peritoneal dialysis (PD). She walks a quarter of a mile daily in an effort to stay mobile and healthy and is very invested in her grandchildren and great-grandchildren, of whom she has many. She and her family recognize the difﬁculties of hemodialysis (HD) but still want to try for at least a while. She is eating well and has not lost weight..
Question: What is the single best approach to preparing her for dialysis?
1. Have her referred immediately for an arteriovenous ﬁstula so it may mature in time for dialysis
2. Try to convince her to do active medical management/conservative care rather than dialysis because she is a poor candidate for dialysis
3. Refer her to interventional radiology/nephrology for a tunneled dialysis catheter so that it is ready to use when she needs it
4. Follow her closely for uremic symptoms; when she decides to start HD, admit her for nonurgent placement of tunneled dialysis catheter and initiate HD in the hospital
Answer: D
Subject: End-Stage Kidney Disease

A 49-year-old woman with longstanding lithium use has estimated GFR (eGFR) 8 ml/min per 1.73 m2. She has well-compensated bipolar disease and is now off lithium. She makes a signiﬁcant amount of urine daily, and she is otherwise healthy. She is terriﬁed about starting dialysis. She has turned down PD numerous times because she does not wish to infuse ﬂuid into her belly. She has several friends who have promised her a kidney if she would agree to transplantation. She is an electrical engineer and is the chief executive ofﬁcer of a startup company that markets software internet-based video technology, and she does not believe she has time for either PD or three-times-weekly HD..
Question: Which of the following is the best single approach to renal re-placement therapy?
1. Wait until she becomes uremic and admit her for standard three-times-weekly dialysis
2. Refer her for transplantation evaluation and hope for the best
3. Refer her to palliative care to help with conservative therapy
4. Measure her creatinine clearance and discuss with her the possibility of starting dialysis 2 days per week
Answer: D
Subject: End-Stage Kidney Disease

A 54-year-old businessman started on automated PD (APD) 1 year ago. After the initial adjustment, he has ﬁnally adapted to his current APD regimen and enjoys his busy work-life sched-ule. His current APD regimen is 1.5% dextrose solution with a total ﬁll volume of 8 L over 8 hours. He is currently euvolemic with no uremic symptoms and has a good appetite. He is also able to maintain a daily urine output of about 800 ml/day. However, his latest Kt/Vurea is calculated to be 1.6, with BUN 58 mg/dl and creatinine 9.0 mg/dl. His albumin is 3.0 g/L, and hemoglobin is 10.2 g/dl..
Question: Which of the following is the most appropriate option for the management of his APD, following the recent International Society for Peritoneal Dialysis (ISPD) guideline?
1. Increase dwell treatment time to 10 L over 10 hours
2. Add a day dwell of icodextrin
3. Switch him to HD
4. Continue current APD regimen and reassess again later
Answer: D
Subject: End-Stage Kidney Disease

A 60-year-old man has longstanding type 2 diabetes and CKD approaching end stage with an eGFR 9 ml/min. He is not keen for HD and has opted for PD at home..
Question: Which of the following is a better option for an access for his peritoneal dialysis?
1. Straight single-cuff Tenchkoff catheter
2. Straight double-cuff Tenchkoff catheter
3. Coiled single-cuff Tenchkoff catheter
4. Coiled double-cuff Tenchkoff catheter
Answer: B
Subject: End-Stage Kidney Disease

A 45-year-old woman with type 2 diabetes, a history of ischemic heart disease with prior non-ST-segment elevation myocardial infarction, and hypertension has been on PD for 4 years. On routine follow-up, her BP is 140/80 mmHg on lisinopril 10 mg once daily and carvedilol 12 mg twice daily. Her creatinine is 5.0 mg/dl, and her albumin is 2.7 g/dl. She takes atorvastatin 40 mg once daily, and her lipid proﬁle is as follows: total cholesterol 300 mg/dl, LDL 180 mg/dl, and HDL 48 mg/dl. She has had four episodes of peritonitis over the past 4 years on PD..
Question: Based on recent studies and KDIGO guidelines, which of the following would be expected to improve her long-term outcome?
1. Increasing her statin dose to target a lower LDL
2. Review the causes of her episodes of peritonitis to reduce risk of recurrence
3. Escalate her antihypertensives to target BP at < 130/ 80 mmHg
4. Stop the angiotensin-converting enzyme inhibitor to im-prove her residual renal function (RRF)
Answer: B
Subject: End-Stage Kidney Disease

A 60-year-old man with stage 5 CKD due to longstanding type 2 diabetes, eGFR 6 ml/min, and a urine output of approximately 800 ml/day presented with ﬂuid overload and uremic symptoms of nausea, fatigue, and anorexia. He has repeatedly defaulted outpatient follow-up in the past 6 months owing to poor acceptance of disease trajectory. On physical examination, his BP was 160/82, and pulse oxygen saturation was 92% on room air. He had bibasal crackles on lung examination and 2+ ankle edema. His serum creatinine was 13 mg/dl, and serum potassium was 5.2 mmol/L. After lengthy discussion, he opted to initiate PD..
Question: Which one of the following is the BEST option for preserving his RRF?
1. Add oral loop diuretics
2. Start with twice daily PD exchanges, then gradually step up
3. Use low-glucose degradation product and neutral pH bio-compatible PD solutions
4. Start him with automated PD
Answer: C
Subject: End-Stage Kidney Disease

A 69-year-old man with ESKD due to diabetes, and a history of ischemic heart disease, presents to clinic complaining of in-creased exertional dyspnea over the past 2 weeks. He started continuous ambulatory PD (CAPD) 3 years ago. His current CAPD regimen consists of three exchanges using 2 L of 1.5% standard PD solution. He does not record his UF volume and admits that he sometimes shortens dwell time to 4 hours. On physical examination, BP is 125/86 mmHg, body weight is 80 kg, and there is no pedal edema. Weekly Kt/Vurea is 1.6, and 24-hour urine collection showed residual urine of 547 ml. His serum albumin was 29 g/dl. Peritoneal equilibration tests demonstrate dialysate-to-plasma creatinine ratio at 4 hours was 0.47, identifying him as having low transporter status..
Question: Bioimpedance spectroscopy indicated that volume of overhydration was + 3.6 L.
In addition to reinforcing dietary and PD compliance, which of the following strategies will improve this patient’s ﬂuid overload?
1. Switch to automated PD
2. Arrange serial bioimpedance spectroscopy
3. Change to three bags of 1.5% 2-L low-glucose degradation product neutral pH solution
4. Add furosemide 250 mg daily
Answer: D
Subject: End-Stage Kidney Disease

You are asked to review the rate of CAPD peritonitis for a quality improvement project at your local center..
Question: Based on the ISPD 2016 guideline, at which of the following levels of culture-negative peritonitis, among all the peritonitis episodes, should a review of sampling and culture methods be carried out?
1. More than 5%
2. More than 10%
3. More than 15%
4. More than 20%
Answer: C
Subject: End-Stage Kidney Disease

A 54-year-old man who has been on PD for 2 years was admit-ted with abdominal pain and cloudy peritoneal ﬂuid. A diagnosis of CAPD peritonitis is made, and intraperitoneal cefazolin and ceftazdime were started as ﬁrst-line antibiotics. He is now afebrile, but his peritoneal ﬂuid remains cloudy. His peritoneal ﬂuid culture has grown out Enterococcus species, and sensitivity results are pending..
Question: Which of the following may be the most suitable next choice of antibiotics?
1. Continue intraperitoneal cefazolin, given that he is now afebrile
2. Add intraperitoneal gentamicin
3. Add intraperitoneal linezolid
4. Switch to oral amoxicillin
Answer: D
Subject: End-Stage Kidney Disease

A 77-year-old woman with heart failure with preserved ejection fraction, type 2 diabetes, and CKD stage 5, and with eGFR 13 ml/min, comes to your clinic for follow-up. She has had three admissions for decompensated heart failure in the prior 4 months and reports worsening lower limb edema despite escalating diuretics. Her BUN has risen to 104 mg/dl, and her most recent creatinine is 3.5 mg/dl. Her energy has declined over the past month and she wishes to discuss her options for starting dialysis..
Question: Which of the following is correct with regard to initiation of PD?
1. Patients who start on “full-dose” PD have similar preservation of RRF as those who start with incremental PD
2. APD is associated with a lower risk of technique failure than CAPD
3. Biocompatible PD solutions have been associated with lower rates of PD peritonitis
4. Use of icodextrin-based PD solutions are associated with more rapid loss of RRF
Answer: B