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Persistent invisible haematuria with A3 albuminuria in optimally treated diabetic kidney disease — MSRA MCQ

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HardMicrohematuriaPersistent invisible haematuria with A3 albuminuria in optimally treated diabetic kidney diseaseMSRA

A 55-year-old woman with type 2 diabetes attends for annual review. She has no visible haematuria, dysuria, urinary frequency, fever, loin pain, recent urinary instrumentation or vigorous exercise. She does not smoke. Three correctly collected early-morning urine samples over 4 months show blood 1+, blood 2+ and blood 1+ on reagent strip. All midstream urine cultures show no significant growth. Urine ACR is 86 mg/mmol and 91 mg/mmol on two early-morning samples 13 weeks apart. Her eGFR is stable at 84 mL/min/1.73 m² and blood pressure is 126/72 mmHg. She takes metformin, empagliflozin and irbesartan 300 mg daily. Her diabetic kidney disease treatment is considered optimised. 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: B — Refer for specialist renal assessment while continuing current optimised diabetic kidney disease treatment

Explanation lettering: E = shown as A · A = shown as E

This patient has persistent invisible haematuria: at least 2 of 3 reagent-strip samples are positive at 1+ or greater. NICE advises using reagent strips for this purpose and not using urine microscopy to confirm a positive result. Her repeated ACR values also establish persistent A3 albuminuria despite preserved eGFR. NICE recommends specialist renal assessment for adults with an ACR above 30 mg/mmol together with haematuria. Although the separate ACR threshold of 70 mg/mmol has an exception where albuminuria is known to be caused by diabetes and is appropriately treated, that exception does not remove the independent referral indication of ACR above 30 mg/mmol plus haematuria. Therefore, renal referral is indicated while maintaining her established renoprotective treatment. A is appropriate for persistent isolated invisible haematuria without proteinuria, not for this combination. C is not indicated by NICE NG12: non-visible haematuria triggers a bladder suspected-cancer-pathway referral only from age 60 when accompanied by dysuria or raised white cell count. D is contrary to NICE advice. E delays referral despite already repeated, diagnostic ACR results. ([nice.org.uk](https://www.nice.org.uk/guidance/ng203/chapter/Recommendations?utm_source=openai))

Reference: NICE NG203: Chronic kidney disease: assessment and management — recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — recommended actions organised by symptom and primary-care findings (2015; page current when checked August 2026) — https://www.nice.org.uk/guidance/NG12/chapter/recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations