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Persistent invisible haematuria with CKD G2 A3 — MSRA MCQ

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HardMicrohematuriaPersistent invisible haematuria with CKD G2 A3MSRA

A 58-year-old man has had urine reagent-strip testing on three correctly collected early-morning samples over 4 months because of hypertension review. Results show blood 1+, blood 2+ and blood 1+. He has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss or recent vigorous exercise. Three urine cultures show no significant growth. His blood pressure is 134/80 mmHg on amlodipine. eGFR is stable at 74 mL/min/1.73 m². Urine ACR is 48 mg/mmol on two early-morning samples obtained 3 months apart. Full blood count is normal. There is no diabetes, known urological disease or family history of inherited kidney disease. What is the most appropriate next management plan?

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

Reveal the answer and explanation

Correct answer: B — Refer for nephrology assessment and arrange renal ultrasonography

Explanation lettering: D = shown as B · B = shown as D

This patient has persistent invisible haematuria because at least 2 of 3 reagent-strip tests are positive. He also has confirmed A3 albuminuria (ACR greater than 30 mg/mmol on samples separated by 3 months), establishing CKD despite a preserved eGFR. NICE recommends specialist nephrology assessment for adults with ACR greater than 30 mg/mmol together with haematuria. NICE also recommends renal ultrasonography for adults with CKD and persistent invisible haematuria. A is inappropriate because annual surveillance is the approach for persistent isolated invisible haematuria in the absence of proteinuria, not for haematuria with A3 albuminuria. B is plausible because urinary tract malignancy must be considered, but routine urology referral alone fails to address the specific nephrology referral criterion and renal assessment indicated by albuminuria plus haematuria. C is not indicated by NICE NG12: suspected cancer pathway referral for non-visible haematuria requires age 60 years or over plus either dysuria or a raised white cell count; neither applies here. E is inappropriate because repeated cultures are negative and he has no symptoms of UTI.

Reference: NICE NG203: Chronic kidney disease: assessment and management — haematuria, renal ultrasound and referral criteria (2021; page checked August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — bladder cancer (2015; page checked August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer