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Suspected acute nephritis causing acute kidney injury — MSRA MCQ

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HardHematuriaSuspected acute nephritis causing acute kidney injuryMSRA

A 54-year-old man presents with 3 days of dark-red urine and reduced urine output. Ten days earlier he had a self-limiting sore throat. He has no dysuria, frequency, loin pain, fever, recent urinary instrumentation or anticoagulant use. His blood pressure is 168/102 mmHg and he has new bilateral ankle oedema. Urine dipstick shows 3+ blood and 3+ protein, with negative nitrites and leucocytes. A midstream urine culture shows no significant growth. Serum creatinine is 136 micromol/L; it was 78 micromol/L 6 days ago. Potassium is 4.8 mmol/L. What is the most appropriate management plan today?

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Correct answer: A — Arrange same-day acute medical assessment and discuss suspected acute nephritis with nephrology within 24 hours

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

This man has acute kidney injury: creatinine has increased from 78 to 136 micromol/L in 6 days, a rise of more than 50%. The combination of AKI, hypertension, oedema, haematuria and substantial proteinuria, without evidence of UTI or catheter trauma, is strongly suggestive of an acute nephritic/glomerular process. NICE advises considering acute nephritis and referring to nephrology in this setting; where possible glomerulonephritis may require specialist treatment, management should be discussed with nephrology as soon as possible and within 24 hours. Same-day acute assessment is appropriate because renal function is deteriorating and the diagnosis may be time-critical. A is initially attractive because he is over 45 with visible haematuria, which ordinarily meets criteria for a suspected cancer pathway referral when unexplained. However, the immediate priority is AKI with suspected glomerulonephritis rather than an outpatient cancer pathway. B risks delaying assessment of a potentially rapidly progressive renal disorder. C may form part of AKI investigation if no cause is identified or obstruction is suspected, but imaging must not delay acute nephrology input. E is inappropriate because there are no urinary symptoms, pyuria, nitrites or positive culture supporting UTI.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management — Recommendations (2013; current NICE guidance checked 15 August 2026) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG148: Acute kidney injury: prevention, detection and management — Referral to nephrology (2013; current NICE guidance checked 15 August 2026) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — Haematuria (2015; current NICE guidance checked 15 August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations