SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Acute Kidney Injury & Critical Care Nephrology
A 63-year-old kidney transplant recipient is seen in consultation for stage 2 AKI complicating urosepsis. She has received 4 L Ringer’s lactate solution over the past 8 hours. She remains intubated and ventilated, and she requires support with norepinephrine and vasopressin. Laboratory studies show sodium 138 mEq/L, potassium 4.9 mEq/L, chloride 98 mEq/L, total CO2 18 mmol/L, BUN 36 mg/dl, and creatinine 2.6 mg/dl (increased from her most recent values, which averaged 1.1 mg/dl). An arterial blood gas shows pH 7.17 and PaCO2 20 mmHg. In the setting of acidosis, AKI, and shock, you recommend an infusion of 4.2% sodium bicarbonate titrated to achieve an arterial pH of7.30..
Question: In this setting, administration of bicarbonate as speciﬁed will be associated with which ONE of the following outcomes?
A. Increased risk of mortality
B. Increased risk of hypercalcemia
C. Decreased risk of progressive AKI requir-ing dialysis
D. Decreased risk of intensive care unit-associated delirium
E. Fewer vasopressor-free days
Answer: C
Subject: Acute Kidney Injury & Critical Care Nephrology
You are admitting a 65-year-old kidney trans-plant recipient with presumed urosepsis. The patient is confused, disoriented, and hypotensive, with a blood pressure of 90/55 mmHg. The temperature is 39.1C. The oxygen saturation is 88% on ambient air. The oxygen saturation in-creases to 93% after initiation of oxygen at 4 L/min by nasal cannula. Laboratory studies show serum sodium 132 mEq/L, potassium 3.6 mEq/L, chloride 95 mEq/L, total CO2 18 mmol/L, BUN 18 mg/dl, creatinine 1.4 mg/dl (increased from 1.1 mg/dl 3 months ago), leukocyte count 15,200/µl, hemoglobin 6.8 g/dl, and platelet count 126,000/µl..
Question: Which ONE of the following is the MOST important step in mitigating this patient’s morbidity and mortality in the setting of impending septic shock?
A. Administration of a bolus of 30 ml/kg 0.9% normal saline solution
B. Administration of vasopressors to achieve a mean arterial pressure of 70 mmHg
C. Administration of a combination of ﬂuids and vasopressors to achieve a target central venous saturation of 70%
D. Early administration of appropriate antibiotics
Answer: D
Subject: Acute Kidney Injury & Critical Care Nephrology
You are meeting with your hospital’s chief information ofﬁcer and her team. They have several questions for you regarding the ability of the electronic medical records to improve the care of patients with AKI and also of those at risk for AKI. Although electronic alerts that are not linked to care bundles or action items have not universally led to improved outcomes, subsequent analyses have demonstrated there are still subgroups of patients who may derive a clinical beneﬁt from electronic AKI alerts..
Question: Which ONE of the following individuals is MOST likely to beneﬁt from electronic alerts in the medical record that identify AKI?
A. A 35-year-old woman with serum creatinine that has increased from 0.7 mg/dl to 2.4 mg/dl over 1 day
B. A 76-year-old woman with serum creatinine that has increased from 0.7 mg/dl to 1.0 mg/dl over 3 days
C. A 68-year-old woman with serum creatinine that has increased from 0.7 mg/dl to 2.4 mg/dl over 1 day
D. A 66-year-old man with serum creatinine that has increased from 0.7 mg/dl to 2.4 mg/dl over 3 days
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology
The chief quality ofﬁcer at your institution asks for your advice about clinical decision support systems and decision-making algorithms developed for AKI..
Question: Based on the existing literature, implementing such electronic medical record support will result in which ONE of the following improvements in care for patients with and at risk for AKI?
A. A reduction in nephrotoxin exposure and events requiring renal replacement therapy (RRT), but no change in hospital mortality
B. A reduction in renal replacement therapy (RRT) events, inpatient mortality, and radiocontrast exposure
C. No change in nephrotoxin exposure or renal replacement therapy (RRT) events, but a reduction in inpatient mortality
D. Uniform reductions in nephrotoxin expo-sure and inpatient mortality, but no change in renal replacement therapy (RRT) events
E. A reduction in nephrotoxin exposure, but no change in renal replacement therapy (RRT) events and inpatient mortality
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology
Several weeks after joining a new practice, you note that you are often consulted late into the course of AKI. You discuss the relative merits of implementing an alert system that activates a prompt recommending nephrology consultation at the time of a clinically signiﬁcant increase in the serum creatinine level or a decrease in urine output..
Question: Which ONE of the following outcomes has been demonstrated to result from implementation of nephrology consultation prompted by an AKI alert system?
A. Fewer cases of severe AKI, but no difference in early nephrology consultation or renal recovery
B. Fewer cases of severe AKI and increased early nephrology consultation, but no change in renal recovery
C. Fewer cases of severe AKI, a higher incidence of renal recovery, and increased early nephrology consultation
D. No change in the rate of severe AKI, increased early nephrology consultation, and a higher incidence of renal recovery
Answer: C
Subject: Acute Kidney Injury & Critical Care Nephrology
Question: Question 2833:
Implementing a Kidney Disease Improving Global Outcomes—based care bundle for post-operative patients with urinary tissue inhibitor of metalloproteinase 2*IGF binding protein factor 7 levels > 0.3 [(ng/ml)2/1000] MOST consistently leads to which ONE of the following patient outcomes?
A. Shorter length of mechanical ventilation
B. Decreased rate of stage 2 and 3 AKI
C. Decreased requirement for RRT
D. Reduced inpatient mortality
E. Decreased urine output
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology
A 28-year-old woman with ESRD receives a de-ceased donor kidney transplant. She is given a 100-mg dose of intravenous furosemide after successful anastomosis of the renal vessels. Two hours after furosemide administration, the sub-sequent urine output is noted to be 82 ml..
Question: This patient’s urine output in response to intravenous furosemide (furosemide stress test) BEST predicts which ONE of the following outcomes?
A. Acute renal allograft rejection
B. 1-year mortality
C. Delayed graft function after renal transplantation
D. 1-year graft survival after renal transplantation
Answer: C
Subject: Acute Kidney Injury & Critical Care Nephrology
Question: Question 2835:
Which ONE of the following patients has the LOWEST risk of AKI?
A. 56-year-old man with fulminant hepatic failure due to acetaminophen toxicity re-quiring emergent liver transplantation and a high modiﬁed Model for End-stage Liver Disease score of 32
B. A 62-year-old man with a stage G3a:A1 CKD (eGFR 46 ml/min per 1.73 m2) scheduled for elective coronary artery by-pass surgery with a GFR that increases by 42 ml/min per 1.73 m2 after a protein load of 1.2 g/kg body weight
C. A 38-year-old woman with Child-Pugh class C cirrhosis, baseline serum creatinine of 1.3 mg/dl, receiving a 4-week course of ceftazidime and gentamicin for gram negative bacteremia
D. A 70-year-old woman with stage G4 CKD (eGFR 28 ml/min per 1.73 m2), chronic systolic heart failure, with cardiogenic shock because of acute ischemic papillary muscle rupture now requiring an intra-aortic balloon pump and emergency mitral valve replacement
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology
A 28-year-old man in your hospital’s neuro-intensive care unit has just been declared brain dead after a motorcycle accident that was associated with signiﬁcant head trauma. His family and physicians are interested in determining whether he is a viable candidate for kidney donation. Although you do not have any baseline information about his kidney function, his serum creatinine level has risen from 1.2 mg/dl to 1.4–1.6 ml/dl over the past 2 weeks..
Question: Which ONE of the following biomarkers is MOST likely to predict renal tubular injury on biopsy beyond that predicted by the serum creatinine level?
A. Urine kidney injury molecule-1
B. Urine neutrophil gelatinase-associated lipocalcin
C. Urine liver–fatty acid binding protein
D. Urine interleukin-18
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology
A 65-year-old woman with class II New York Heart Association (NYHA) heart failure, hypertension, and type 2 diabetes mellitus is under-going an evaluation for aortic valve replacement. Her baseline serum creatinine level is 2.1 mg/dl and the urine albumin-to-creatinine ratio is 536 mg/g. An echocardiogram shows a normal ejection fraction and moderate left ventricular hypertrophy..
Question: Based on the available data, which ONE of the following statements is MOST accurate re-garding her risk of postoperative AKI?
A. Her baseline serum creatinine is not a risk factor for postoperative AKI
B. The transcatheter approach for aortic valve replacement may be associated with a lower risk of AKI compared with a surgical approach
C. Albuminuria, but not serum creatinine, predicts the risk of postoperative AKI
D. Left ventricular dysfunction, but not NYHA heart failure class, is associated with AKI risk
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology
A 70-year-old man with stage G3b:A3 CKD, diabetes mellitus, and hypertension is seen in consultation before coronary angiography. There is no history of congestive heart failure, and the physical examination is normal except for signs of diabetic retinopathy and neuropathy. An echocardiogram shows normal left ventricular function. You are asked to recommend the best prophylactic regimen to prevent AKI. His eGFR is 43 ml/min per 1.73 m2. The urine albumin-to-creatinine ratio is 978 mg/g..
Question: Which ONE of the following recom-mendations is MOST consistent with the ﬁndings of the Prevention of Serious Adverse Events Following Angiography (PRESERVE) trial?
A. N-acetylcysteine should be administered 2 days before radiocontrast exposure to reduce the risk of dialysis-requiring AKI in this high-risk patient
B. Intravenous isotonic bicarbonate infusion is superior to isotonic saline solution in this patient, who does not have congestive heart failure
C. Neither N-acetylcysteine compared with placebo nor isotonic bicarbonate therapy compared with saline solution is more likely to reduce the risk of dialysis-requiring AKI after radiocontrast exposure
D. He should receive both isotonic bicarbonate and N-acetylcysteine for prophylaxis because he is at extremely high risk for contrast-induced nephropathy
Answer: C
Subject: Acute Kidney Injury & Critical Care Nephrology
A 60-year-old man with diabetes mellitus, hyper-tension, and chronic obstructive pulmonary dis-ease is admitted to the hospital with pneumonia. Blood cultures grow Pseudomonas aeruginosa. Over the next 48 hours, he experiences acute respiratory distress syndrome, hypotension requiring hemodynamic support with vasopressors, and oliguric stage 3 AKI. It is determined that continuous RRT is the best dialysis option..
Question: Which ONE of the following statements most accurately reﬂects current evidence regarding the MOST appropriate modality of dialysis for this patient?
A. Continuous venovenous hemodiaﬁltration is superior to other modalities of solute removal in gram-negative sepsis
B. A polymyxin B adsorptive modality is indicated and has been shown to improve 28-day mortality in patients with endotoxic shock in randomized controlled trials
C. Diffusive solute removal is superior to convective solute removal in this clinical setting with both continuous and intermit-tent therapies
D. There is no signiﬁcant difference in out-comes between diffusive or convective modalities of CRRT
Answer: D
Subject: Acute Kidney Injury & Critical Care Nephrology
A 70-year-old man with stage G3b:A2 CKD, diabetes mellitus, and hypertension is seen in the ofﬁce after a recent hospitalization for hip surgery. His hospital course was complicated by stage 1 AKI. His baseline serum creatinine level was 1.9 mg/dl. While he was hospitalized, the serum creatinine level peaked at 3.1 mg/dl and eventually fell to the current level of 2.1 mg/dl..
Question: Which ONE of the following is the MOST accurate statement regarding the impact of the AKI episode on his long-term cardiovascular prognosis?
A. It has no impact on his subsequent risk of cardiovascular events
B. It increases his risk of incident congestive heart failure
C. It is not associated with subsequent cardiac events because he did not experience dialysis-requiring AKI
D. It is not associated with cardiac events because the kidney function almost com-pletely recovered to baseline
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology
A 55-year-old man with diabetes mellitus is evaluated in consultation for AKI complicating a 25% total body surface area burn and septic shock. The BUN and serum creatinine have risen from 46 mg/dl and 1.5 mg/dl on admission to 100 mg/dl and 5.7 mg/dl, respectively. The urine output has fallen to < 200 ml over the past 24 hours. The blood pressure is 108/60 mmHg on vasopressors, and the central venous pressure is 14 cm H2O. The intensivists caring for the patient ask you about high-dose continuous renal replacement therapy (RRT)..
Question: Which ONE of the following should you tell them about dialysis dose and modality based on evidence derived from randomized controlled trials?
A. Continuous renal replacement therapy (RRT), if chosen, should be provided with efﬂuent ﬂow rate of at least 35 ml/kg per h
B. Continuous renal replacement therapy (RRT), if chosen, should be provided with efﬂuent ﬂow rate of at least 20 ml/kg per h
C. Continuous venovenous hemoﬁltration should be chosen over continuous venovenous hemodialysis because it offers a survival advantage in this patient
D. Randomized trials support high-volume efﬂuent ﬂow of 70 ml/kg per h in this clinical setting
Answer: b
Subject: Acute Kidney Injury & Critical Care Nephrology
A 72-year-old woman is seen in consultation for AKI complicating acute decompensated heart failure..
Question: Which ONE of the following types of cardiac dysfunction is associated with the HIGHEST risk of mortality in this patient with AKI?
A. Isolated severe right ventricular systolic dysfunction (right ventricular ejection frac-tion of 25%)
B. Diastolic dysfunction with normal left ventricular systolic function
C. Mild biventricular systolic dysfunction (right and left ventricular ejection fractions of 50%)
D. Modest left ventricular systolic dysfunction (left ventricular ejection fraction of 45%)
Answer: A
Subject: Acute Kidney Injury & Critical Care Nephrology
A 72-year-old man with pneumonia due to Staphylococcal aureus is seen in consultation for nonoliguric AKI. He has been treated with intravenous vancomycin, and trough levels have ranged between 15 and 20 mg/L. On physical examination, he appears frail and is in mild respiratory distress. The blood pressure is 130/ 80 mmHg, and the temperature is 38.1C. There are crackles and bronchial breath sounds in the left lower lung zone. There is trace peripheral edema. Over the past 3 days, the serum creatinine level has risen from 1.2 mg/dl to 2.4 mg/dl. The urinalysis shows 1+ protein, no blood, and 5 to 10 muddy brown casts per high-power ﬁeld..
Question: Which ONE of the following should you indicate in your consultation?
A. Trough levels of 15 to 20 mg/L are not associated with nephrotoxicity
B. Only peak vancomycin levels correlate with nephrotoxicity
C. No change in vancomycin dosing is warranted because he does not have oliguria
D. Vancomycin nephrotoxicity has been associated with trough levels greater than or equal to 15 mg/L
Answer: D
Subject: Acute Kidney Injury & Critical Care Nephrology
You are asked to see a 79-year-old woman with inﬂuenza A complicated by secondary bacterial pneumonia and sepsis for AKI. She has been receiving vancomycin and piperacillin-tazobactam since admission 5 days ago. The serum creatinine has risen from 0.6 mg/dl to 1.7 mg/dl, and the urine volume has decreased to 500 ml per day. On physical examination, she is confused and bedridden. The blood pressure is 110/60 mmHg, the heart rate is 110/min, and the respiratory rate is 22/min. The lung examination reveals diffuse crackles in the lower lung zones bilaterally. The pulse is irregularly irregular. There is no cardiac murmur. There is 1+ pretibial edema. The urinalysis shows 1+ protein and many muddy brown casts. Vancomycin trough levels are 16 to 20 mg/L..
Question: Which ONE of the following statements is the MOST accurate regarding antibiotic-mediated renal toxicity in this patient?
A. Vancomycin nephrotoxicity is unlikely because trough levels are not greater than 25 mg/L
B. Vancomycin/piperacillin-tazobactam nephrotoxicity is unlikely in the absence of leukocyte casts
C. The combination of vancomycin and piperacillin-tazobactam is associated with a higher risk of AKI than either antibiotic alone
D. Urgent dialysis is indicated to reduce vancomycin levels and prevent further toxicity
Answer: C
Subject: Acute Kidney Injury & Critical Care Nephrology
A 67-year-old man with type 2 diabetes mellitus and hypertension is admitted to the coronary intensive care unit with acute decompensated heart failure. He is seen in consultation because of a rise in his serum creatinine from 1.0 mg/dl on admission to 1.3 mg/dl 3 days later. He has received intermittent boluses of intravenous furo-semide, with a net diuresis of 3 kg, which resulted in an improvement in his congestive symptoms. The serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) level declined 35% from the admission level, which was initially elevated threefold above the reference range..
Question: Which ONE of the following statements BEST characterizes the association between kidney and cardiac dysfunction in this patient?
A. The reduction in the NT-proBNP level of > 30% is associated with improved sur-vival independent of the change in kidney function
B. The beneﬁts of lowering NT-proBNP with diuresis are negated by the risks of con-comitant worsening of kidney function
C. Neither the degree of change in NT-proBNP level nor the percentage change in creati-nine is of prognostic signiﬁcance in this patient
D. The weight reduction of 3 kg is the most important predictor of improved outcomes in this patient
Answer: A
Subject: Acute Kidney Injury & Critical Care Nephrology
A 76-year-old woman with chronic systolic heart failure is admitted with acute decompen-sated heart failure. Her home medication regimen included bumetanide 1 mg once daily and lisinopril. She is initially treated with increased doses of bumetanide and lisinopril. The serum creatinine rises from 1.6 mg/dl on admission to 2.1 mg/dl and is associated with onset of transient oliguria. The doses of bumetanide and lisinopril are reduced, and the serum creat-inine subsequently falls to 1.6 mg/dl on the third hospital day, with resolution of oliguria. She is discharged on an increased dose of bumetanide (1 mg twice daily) and her usual dose of lisinopril..
Question: Which ONE of the following statements MOST accurately reﬂects her short-term prognosis?
A. She is not at a risk for readmission because she experienced stage 2 but not stage 3 AKI
B. Although she experienced transient azote-mia that returned to baseline within 3 days, she still is at a higher risk for readmission than are patients without AKI
C. Given that her kidney function almost completely recovered to baseline, she is no longer at increased risk for adverse outcomes after discharge
D. Transient oliguria is more important than rise of creatinine is predicting the risk of readmission
Answer: B
Subject: Acute Kidney Injury & Critical Care Nephrology
A 70-year-old woman with advanced CKD due to diabetic nephropathy is evaluated before initia-tion of dialysis. She required coronary artery bypass surgery 2 months ago, which was com-plicated by stage 2 AKI. While hospitalized, the serum creatinine level rose from 2.0 mg/dl to 4.0 mg/dl. Although the creatinine at discharge had improved slightly to 3.5 mg/dl, she subsequently had progressive CKD. She now has subtle uremic symptoms and a mild degree of volume overload. On physical examination, she is in no distress. The blood pressure is 130/80 mmHg. There is 1+ leg edema. The remainder of the examination is unremarkable. Laboratory studies show serum sodium 138 mEq/L, potassium 5.4 mEq/L, chloride 102 mEq/L, total CO2 19 mmol/L, BUN 92 mg/dl, creatinine 8.5 mg/dl, calcium 9.2 mg/dl, and phosphorus 5.9 mg/dl. The hemoglobin is 10.2 g/dl. Plans are under way to start dialysis in the outpatient setting next week. She has an arteriovenous ﬁstula that is ready for use..
Question: Which ONE of the following statements MOST accurately characterizes the prognostic importance of AKI before initiation of long-term dialysis?
A. Her history of AKI in the predialysis period does not affect her mortality
B. The episode of AKI will not affect her survival on dialysis because she has an arteriovenous ﬁstula
C. Given her history of AKI before initiation of dialysis, she should initiate dialysis in a hospitalized setting
D. Her pre-ESRD episode of AKI is associ-ated with a 30% greater risk of mortality at 1 year in comparison with patients without AKI before incident dialysis
Answer: D
Subject: Acute Kidney Injury & Critical Care Nephrology
A 65-year-old man with stage G3a CKD is seen in consultation before coronary artery bypass grafting surgery..
Question: Which ONE of the following should you tell his surgeon with regard to on-pump versus off-pump cardiopulmonary bypass and his risk of AKI?
A. Off-pump surgery in eligible patients is associated with a reduced risk of AKI during the ﬁrst postoperative month
B. Off-pump cardiac surgery is associated with long-term preservation of renal function at 1 year
C. On-pump surgery poses no additional risk than off-pump surgery when the time on pump is < 90 minutes
D. On-pump surgery is preferred because it provides greater renal blood ﬂow during the surgery
Answer: A
Subject: Acute Kidney Injury & Critical Care Nephrology
A 44-year-old man with metastatic melanoma is referred for AKI. He started combination therapy with nivolumab (an antibody-inhibiting programmed cell death protein 1 [PD-1]) and ipilimumab (a cytotoxic T-lymphocyte-associated protein 4 [CTLA-4] inhibitor) 2 months ago. Over the past 6 weeks, the serum creatinine level has risen from 1.3 mg/dl to 2.8 mg/dl. Serum complement levels are normal. A complete blood count shows leukocyte count 6500/µl, hemoglobin 12.9 g/dl, and platelets 427,000/µl. The absolute eosinophil count is elevated at 2300/µl (reference range < 400/µl). The urinalysis shows 5 to 10 leukocytes per high-power ﬁeld and occasional leukocyte casts. The urine protein-to-creatinine ratio is 3204 mg/g, and the urine albumin-to-creatinine ratio is 2986 mg/g..
Question: Which ONE of the following lesions is the MOST likely to be found on kidney biopsy?
A. Acute tubulointerstitial nephritis with podocyte injury
B. Renal-limited thrombotic microangiopathy
C. Immune complex–mediated glomerulonephritis
D. Minimal change glomerulopathy with acute tubular necrosis
E. Secondary membranous nephropathy
Answer: A