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

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HardMicrohematuriaChronic kidney disease with persistent invisible haematuria and severe albuminuriaMSRA

A 44-year-old man is reviewed after incidental non-visible haematuria during an insurance medical. He has no visible haematuria, dysuria, frequency, loin pain, fever, weight loss, urinary tract infection symptoms, recent instrumentation or vigorous exercise. He does not smoke. Urine reagent-strip testing on three correctly collected early-morning samples over 4 months shows blood 1+, blood 2+ and blood 1+. Midstream urine cultures are negative. Urine ACR is 82 mg/mmol and 76 mg/mmol on two early-morning samples 12 weeks apart. His eGFR is stable at 71 mL/min/1.73 m². Blood pressure is 142/88 mmHg despite amlodipine 10 mg daily. Potassium is 4.3 mmol/L. He does not have diabetes. What is the most appropriate next management plan?

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

Reveal the answer and explanation

Correct answer: A — Arrange renal ultrasound scanning, refer for nephrology assessment, and offer an ACE inhibitor or ARB titrated to the highest tolerated licensed dose

This man has persistent invisible haematuria, defined by at least 2 positive reagent-strip tests from 3 samples. He also has persistent severe albuminuria (ACR 76–82 mg/mmol), establishing CKD despite preserved eGFR. NICE recommends nephrology referral for CKD with ACR 70 mg/mmol or more, and recommends offering an ACE inhibitor or ARB to adults without diabetes who have ACR of 70 mg/mmol or more, titrated to the highest tolerated licensed dose. Persistent invisible haematuria in an adult with CKD is also an indication for renal ultrasound. A is inappropriate because he does not meet NICE suspected-cancer pathway criteria for non-visible haematuria: he is under 60 and has neither dysuria nor an unexplained raised white cell count. B inadequately addresses the high-risk albuminuria, which requires nephrology assessment rather than routine surveillance alone. C includes appropriate renin–angiotensin system blockade but wrongly delays referral and omits indicated ultrasound. D includes ultrasound but fails to address both the nephrology-referral threshold and disease-modifying treatment for marked albuminuria.

Reference: NICE NG203: Chronic kidney disease: assessment and management (2021 recommendations; page checked 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management (2021 recommendations; page checked 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management (2021 recommendations; page checked 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations