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Persistent invisible haematuria with A3 albuminuria — MSRA MCQ

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HardHematuriaPersistent invisible haematuria with A3 albuminuriaMSRA

A 59-year-old woman presents with 4 months of intermittent dysuria. She has no visible haematuria, fever, loin pain, vaginal bleeding, vaginal discharge, urinary frequency or weight loss. Three properly collected midstream urine samples show 2+ blood on reagent-strip testing; all cultures show no significant growth. Early-morning urine ACR is 36 mg/mmol and 41 mg/mmol on repeat testing 3 months later. Her eGFR is 82 mL/min/1.73 m², blood pressure is 126/76 mmHg and full blood count, including white cell count, is normal. What is the most appropriate next management plan?

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Correct answer: D — Arrange renal ultrasound and refer for nephrology assessment

This patient has persistent invisible haematuria: NICE regards 2 positive reagent-strip tests out of 3 as confirmation when distinguishing persistent from transient haematuria. She also has persistent A3 albuminuria, with two early-morning ACR measurements above 30 mg/mmol separated by 3 months, despite preserved eGFR. NICE recommends specialist assessment for adults with an ACR above 30 mg/mmol together with haematuria. In addition, renal ultrasound is indicated in adults with CKD who have persistent invisible haematuria. A suspected cancer pathway referral for bladder cancer is not the best answer. Although she has dysuria with unexplained non-visible haematuria, the NICE threshold for this pathway is age 60 years or over; she is 59. Her age does not remove the need to investigate, but the renal findings establish a nephrology-referral criterion and justify ultrasound. Annual surveillance alone would be appropriate for persistent isolated invisible haematuria without proteinuria or albuminuria after appropriate assessment, but not with confirmed A3 albuminuria. Routine urology referral is less appropriate than the indicated renal pathway at this stage. Further delayed repeat testing is unnecessary because persistence and the referral threshold have already been demonstrated.

Reference: NICE NG203: Chronic kidney disease: assessment and management — haematuria, renal ultrasound and referral criteria (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — bladder cancer (2015, updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer