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Suspected acute nephritis causing acute kidney injury — MSRA MCQ

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HardMicrohematuriaSuspected acute nephritis causing acute kidney injuryMSRA

A 42-year-old man presents with 5 days of lethargy, arthralgia and a new non-blanching purpuric rash on both lower legs. He has not noticed visible haematuria. He is normovolaemic, has no diarrhoea or vomiting, has taken no NSAIDs, and has had no recent urinary catheterisation or instrumentation. His blood pressure is 158/94 mmHg. Serum creatinine was 74 micromol/L 36 hours ago during an urgent-care attendance and is now 112 micromol/L. Urine reagent strip shows blood 2+ and protein 2+, with negative nitrites and leucocytes. Midstream urine culture shows no significant growth. He has no flank pain, lower urinary tract symptoms or palpable bladder. What is the most appropriate immediate management?

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Correct answer: D — Arrange same-day acute medical assessment with urgent nephrology discussion for suspected acute nephritis

This patient has acute kidney injury: his creatinine has risen by 38 micromol/L within 48 hours, exceeding the NICE diagnostic threshold of a 26 micromol/L rise. The combination of AKI, haematuria and proteinuria, with urinary infection and catheter-related trauma excluded, should prompt consideration of acute nephritis and referral to nephrology. The purpuric rash, arthralgia and new hypertension further support a possible systemic glomerular inflammatory process, for which delay could risk rapidly progressive kidney injury. A suspected cancer pathway referral is inappropriate: non-visible haematuria alone does not meet the NICE bladder-cancer threshold, and it would not address the acute intrinsic renal presentation. Outpatient ultrasonography and interval blood tests may be relevant in selected AKI assessment, but do not provide the required urgent specialist assessment for suspected nephritis. Empirical antibiotics are not supported by the negative culture and absence of pyuria or urinary symptoms. Serial testing over months is appropriate only when evaluating otherwise isolated persistent invisible haematuria, not haematuria occurring with AKI and proteinuria.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management — Recommendations (2019; current NICE page checked August 2026) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG148: Acute kidney injury: prevention, detection and management — Urinalysis (2019; current NICE page checked August 2026) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — Haematuria (2015; current NICE page checked August 2026) — https://www.nice.org.uk/guidance/NG12/chapter/recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations