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Unexplained acute kidney injury with nephritic urine dipstick findings — MSRA MCQ

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HardNephrologyUnexplained acute kidney injury with nephritic urine dipstick findingsMSRA

A 54-year-old woman attends for review of blood tests requested because she has felt mildly fatigued for 1 week. She has no fever, diarrhoea, vomiting, rash, joint symptoms, dysuria, loin pain, visible haematuria, lower urinary tract symptoms or reduction in fluid intake. She has hypertension treated with amlodipine only and has not taken NSAIDs, antibiotics, herbal medicines or recreational drugs. Her blood pressure is 136/78 mmHg and she is clinically euvolaemic. Her creatinine was 68 micromol/L (eGFR 92 mL/min/1.73 m²) 6 days ago during an employment medical. Today, creatinine is 111 micromol/L (eGFR 52 mL/min/1.73 m²), potassium 4.8 mmol/L and bicarbonate 24 mmol/L. Urine dipstick shows blood 3+ and protein 3+, with negative nitrites and leucocytes. A midstream urine culture is negative. What is the most appropriate next management plan?

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

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Correct answer: B — Discuss urgently with nephrology within 24 hours and arrange renal tract ultrasound within 24 hours

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

This is acute kidney injury (AKI), not newly recognised CKD: creatinine has risen from 68 to 111 micromol/L within 6 days, a rise of more than 50% within 7 days. There is no convincing pre-renal, drug-related, infective or obstructive explanation. The combination of haematuria and proteinuria without UTI in otherwise unexplained AKI should prompt concern for acute nephritis/glomerulonephritis and urgent nephrology discussion. NICE advises discussion with nephrology as soon as possible, and within 24 hours, when AKI has no clear cause or when a diagnosis requiring specialist treatment, including glomerulonephritis or vasculitis, is possible. NICE also recommends urinary tract ultrasound within 24 hours when AKI has no identified cause. B is incomplete: ultrasound is required, but urology-led management is not the priority in a nephritic urine pattern without obstructive symptoms. C includes reasonable eventual investigations, but these should not delay specialist input. D is inappropriate because AKI and a potentially treatable glomerular process have already been identified. E incorrectly reframes an acute creatinine rise as progressive CKD and delays necessary assessment.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management — Recommendations (Updated 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG148: Acute kidney injury: prevention, detection and management — Urinalysis (Updated 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG148: Acute kidney injury: prevention, detection and management — Ultrasound and nephrology referral (Updated 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations