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Chronic kidney disease with A3 albuminuria and persistent invisible haematuria — MSRA MCQ

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HardNephrologyChronic kidney disease with A3 albuminuria and persistent invisible haematuriaMSRA

A 38-year-old man is reviewed after abnormal results from an insurance medical. He is asymptomatic, normotensive (126/76 mmHg) and has no diabetes, recent infection, urinary symptoms, family history of kidney disease, or NSAID use. eGFR is 74 mL/min/1.73 m² on two measurements 4 months apart. Urine dipstick has shown blood 2+ on two of three samples over the same period; urine culture is negative. Urine ACR was 38 mg/mmol on an initial random sample and 42 mg/mmol on a subsequent early-morning sample. There is no visible haematuria. What is the most appropriate next management step?

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

Reveal the answer and explanation

Correct answer: E — Arrange renal ultrasound and refer for nephrology specialist assessment

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

This man has CKD despite a preserved eGFR: he has persistent markers of kidney damage for more than 3 months. His early-morning ACR confirms A3 albuminuria (>30 mg/mmol), and he has persistent invisible haematuria. NICE recommends specialist nephrology assessment when ACR exceeds 30 mg/mmol in combination with haematuria. NICE also recommends renal ultrasound for all adults with CKD and visible or persistent invisible haematuria. Therefore, both investigations are indicated now. A is inappropriate because annual surveillance applies to persistent invisible haematuria in the absence of proteinuria; this patient has confirmed A3 albuminuria and meets a referral criterion. B is plausible because ACE inhibition is appropriate for some proteinuric CKD, but treatment should not substitute for specialist assessment where A3 albuminuria coexists with haematuria, raising concern for glomerular disease. C omits the required nephrology referral. E over-prioritises malignancy assessment: persistent haematuria should prompt malignancy investigation in appropriate age groups, but this low-risk 38-year-old has a strongly renal pattern requiring nephrology assessment; a suspected-cancer pathway is not the best immediate management on the information given.

Reference: Chronic kidney disease: assessment and management (NG203) — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203) — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203) — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations