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Persistent invisible haematuria with severe albuminuria — MSRA MCQ

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HardMicrohematuriaPersistent invisible haematuria with severe albuminuriaMSRA

A 38-year-old man has incidental non-visible haematuria identified during a life-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 and has no diabetes. Three correctly collected early-morning urine samples over 14 weeks show blood 2+, blood negative and blood 1+ on reagent strip. All urine cultures show no significant growth. Urine ACR is 76 mg/mmol and 81 mg/mmol on early-morning samples taken 12 weeks apart. His eGFR is 94 mL/min/1.73 m², blood pressure is 124/76 mmHg and potassium is 4.2 mmol/L. He takes no regular medication. 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: D — Arrange renal ultrasound, refer for nephrology assessment, and start an ACE inhibitor with eGFR and potassium monitoring

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

This man has persistent invisible haematuria: 2 of 3 reagent-strip tests are positive. NICE advises that microscopy is not required to confirm a positive reagent-strip result. His repeatedly raised ACR (76–81 mg/mmol) is severely increased albuminuria and establishes kidney damage despite a normal eGFR and normal blood pressure. For adults without diabetes and an ACR of 70 mg/mmol or more, NICE recommends both nephrology assessment and treatment with an ACE inhibitor or ARB, titrated as tolerated. Renin–angiotensin system blockade requires baseline eGFR and potassium measurement, repeated 1–2 weeks after initiation and after dose escalation. Persistent invisible haematuria in an adult with CKD also warrants renal ultrasound. Therefore, D addresses the renal risk, proteinuria treatment and required imaging without delay. A is appropriate for isolated persistent invisible haematuria without proteinuria, but misses the ACR threshold for ACE inhibition and nephrology referral. B is tempting because haematuria merits malignancy consideration, but he does not meet NICE suspected bladder-cancer criteria for non-visible haematuria, which require age 60 years or over plus dysuria or raised white-cell count. C omits the indicated renal ultrasound and referral. E delays indicated management and urine microscopy is not recommended to confirm dipstick haematuria.

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