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Persistent non-visible haematuria with A3 albuminuria — MSRA MCQ

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HardHematuriaPersistent non-visible haematuria with A3 albuminuriaMSRA

A 64-year-old man has had dysuria and urinary frequency for 3 months. He has no visible haematuria, fever, loin pain, urethral discharge or recent urinary instrumentation. Three properly collected midstream urine samples have each shown 2+ blood on reagent-strip testing; all cultures showed no significant growth. His urine ACR is 46 mg/mmol on an early-morning sample and 51 mg/mmol on repeat testing. eGFR is stable at 68 mL/min/1.73 m², blood pressure is 128/76 mmHg, and there is no diabetes. Full blood count shows a white cell count of 12.4 × 10⁹/L, confirmed at 12.1 × 10⁹/L 2 weeks later. What is the most appropriate next management step?

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

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Correct answer: D — Arrange a suspected cancer pathway referral for bladder cancer and refer for nephrology assessment

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

This patient needs both urological and nephrological assessment. He is aged 60 years or over and has unexplained non-visible haematuria with dysuria and a persistently raised white cell count, despite repeatedly negative urine cultures. NICE recommends a suspected cancer pathway referral for bladder cancer in this situation. The absence of visible haematuria does not remove this criterion. He also has confirmed A3 albuminuria: ACR is persistently above 30 mg/mmol. NICE CKD guidance recommends nephrology referral when ACR exceeds 30 mg/mmol in the presence of haematuria. Albuminuria may indicate glomerular pathology, but it does not safely explain away the concurrent age-specific bladder-cancer referral indication; the assessments should proceed in parallel. B is incomplete because a qualifying nephrology-referral criterion is already present. C wrongly treats probable renal disease as excluding urological malignancy. D is inappropriate because haematuria and albuminuria have already been confirmed, and delay risks postponing indicated assessment. E applies to persistent isolated invisible haematuria without proteinuria or albuminuria, which is not this case.

Reference: NICE NG12: Suspected cancer: recognition and referral — Bladder cancer, recommendation 1.6.4 (2015; update information checked January 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE NG203: Chronic kidney disease: assessment and management — Referral criteria, recommendation 1.5.5 (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Managing isolated invisible haematuria, recommendations 1.1.17 to 1.1.19 (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations