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Persistent non-visible haematuria with albuminuric chronic kidney disease — MSRA MCQ

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HardMicrohematuriaPersistent non-visible haematuria with albuminuric chronic kidney diseaseMSRA

A 64-year-old postmenopausal woman reports persistent dysuria for 6 weeks. She has no visible haematuria, vaginal bleeding, fever or loin pain. Three urine reagent-strip tests during this period have shown blood 1+, 2+ and 1+. All three urine cultures were negative. She has stable CKD G3a, with an eGFR of 52 mL/min/1.73 m². Her urine albumin:creatinine ratio is 46 mg/mmol and remains elevated at 41 mg/mmol in a subsequent early-morning sample. Full blood count is normal. Which is the most appropriate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Arrange renal ultrasonography and make concurrent suspected bladder cancer and renal specialist referrals.

Explanation lettering: E = shown as A · A = shown as D · D = shown as E

The repeated reagent-strip findings represent persistent non-visible haematuria requiring evaluation; a result of blood 1+ or higher should be evaluated further and does not require confirmation by urine microscopy. Repeated negative cultures make urinary infection an inadequate explanation for the dysuria and haematuria. Because she is aged over 60 and has unexplained non-visible haematuria with dysuria, she meets the NICE criterion for referral through a suspected bladder cancer pathway. The absence of visible haematuria or a raised white cell count does not negate this criterion. A separate renal pathway is also indicated. Her albuminuria has been appropriately confirmed in an early-morning sample and remains in category A3. NICE recommends renal specialist assessment for CKD with an ACR above 30 mg/mmol together with haematuria. Renal ultrasonography is also indicated in an adult with CKD and persistent invisible haematuria. These actions should proceed concurrently rather than making either referral dependent on the ultrasound result. A omits the indicated cancer pathway. B omits the independent renal referral. C may initially fit culture-negative postmenopausal dysuria, but empirical treatment must not defer referrals whose criteria are already met. D incorrectly uses ultrasonography as a triage test and risks delaying both pathways. Therefore, E is the single best answer.

Reference: Suspected cancer: recognition and referral — Recommendations organised by site of cancer (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer Chronic kidney disease: assessment and management — Investigations for proteinuria (Last updated 24 November 2021) — https://www.nice.org.uk/guidance/ng203/chapter/recommendations Chronic kidney disease: assessment and management — Haematuria (Last updated 24 November 2021) — https://www.nice.org.uk/guidance/ng203/chapter/recommendations