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Persistent isolated invisible haematuria — MSRA MCQ

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HardMicrohematuriaPersistent isolated invisible haematuriaMSRA

A 46-year-old woman has urine testing during an occupational health assessment. She has no dysuria, frequency, loin pain, visible haematuria, fever, weight loss or urinary tract infection symptoms. She does not smoke. Three early-morning midstream urine samples, collected outside menstruation and after avoiding vigorous exercise, show blood 1+, negative and blood 1+ on reagent strip. All urine cultures are negative. Her blood pressure is 122/74 mmHg, eGFR is 96 mL/min/1.73 m², urine ACR is 1.1 mg/mmol, full blood count is normal and there is no family history of kidney disease. What is the most appropriate management?

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Correct answer: C — Diagnose persistent invisible haematuria and arrange annual monitoring of blood pressure, eGFR, albuminuria or proteinuria, and haematuria while it persists

This is persistent invisible haematuria: NICE defines persistence as 2 positive reagent-strip tests out of 3 when distinguishing persistent from transient haematuria. Urine microscopy is not required to confirm a positive adult reagent-strip result. She has no albuminuria, reduced GFR, hypertension or systemic features suggesting glomerular disease, so nephrology referral is not indicated. She also does not meet NICE suspected-cancer-pathway criteria for non-visible haematuria: this requires age 60 years or over plus unexplained dysuria or a raised white cell count. Her negative cultures, appropriately collected samples and avoidance of exercise/menstrual contamination make transient or contaminated haematuria less likely, but do not create an urgent cancer-referral indication in this clinical context. Persistent isolated invisible haematuria should therefore be followed annually with repeat haematuria testing, albuminuria/proteinuria assessment, GFR and blood-pressure monitoring for as long as it persists. She should also be safety-netted to seek prompt review if visible haematuria, urinary symptoms, hypertension, proteinuria or reduced renal function develop.

Reference: NICE NG203: Chronic kidney disease: assessment and management — haematuria recommendations 1.1.16 to 1.1.19 (2021) — https://www.nice.org.uk/guidance/ng203/chapter/recommendations NICE NG12: Suspected cancer: recognition and referral — haematuria (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations