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Persistent invisible haematuria with A3 albuminuria — MSRA MCQ

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HardHematuriaPersistent invisible haematuria with A3 albuminuriaMSRA

A 57-year-old postmenopausal woman is reviewed after incidental urine dipstick haematuria. She has had 1+ blood on three properly collected midstream urine samples over 4 months. She has never had visible haematuria and has no dysuria, frequency, loin pain, fever, vaginal bleeding or recent vigorous exercise. Three urine cultures show no significant growth. Her blood pressure is 124/72 mmHg and eGFR is 86 mL/min/1.73 m² on two measurements 4 months apart. Early-morning urine ACR is 38 mg/mmol and 43 mg/mmol on repeat testing. Full blood count, including white cell count, is normal. 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: B — Refer for nephrology assessment and arrange a renal ultrasound scan

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

This patient has persistent invisible haematuria: at least 2 of 3 positive reagent-strip tests confirm persistence. She also has confirmed A3 albuminuria, with ACR above 30 mg/mmol on two early-morning samples, despite preserved eGFR. NICE recommends specialist nephrology assessment for CKD when ACR is greater than 30 mg/mmol in combination with haematuria. NICE also recommends renal ultrasound for all adults with CKD who have visible or persistent invisible haematuria. A is appropriate for persistent isolated invisible haematuria without proteinuria, after appropriate consideration of urinary tract malignancy; it is insufficient here because albuminuria plus haematuria meets nephrology referral criteria. B is initially attractive because persistent haematuria warrants consideration of malignancy, but she is under 60 and has neither dysuria nor a raised white cell count, so she does not meet the NICE suspected cancer pathway criterion for non-visible haematuria. C may become appropriate as part of nephrology-led CKD management, but does not replace indicated referral and imaging. E is premature: biopsy may be considered by nephrology after clinical assessment, serology and ultrasound, rather than being an automatic primary-care next step.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Haematuria (2021; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Indications for renal ultrasound in adults (2021; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Referral criteria (2021; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations