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Type 2 diabetes with CKD G2 A3 and persistent invisible haematuria — MSRA MCQ

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HardNephrologyType 2 diabetes with CKD G2 A3 and persistent invisible haematuriaMSRA

A 58-year-old woman with type 2 diabetes attends for annual CKD review. She takes ramipril 10 mg once daily and dapagliflozin 10 mg once daily; both are tolerated at these doses. Her BP is 126/74 mmHg. eGFR has been stable at 64 to 67 mL/min/1.73 m² over 15 months. Two early-morning urine ACR measurements, 4 months apart, are 96 mg/mmol and 89 mg/mmol. Urine dipstick has shown blood 2+ on 2 of 3 samples over the same period. Midstream urine culture is negative. She has no visible haematuria, dysuria, loin pain, lower urinary tract symptoms or systemic symptoms. White cell count is normal. Her 5-year Kidney Failure Risk Equation risk is 1.6%. What is the most appropriate management plan now?

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

Reveal the answer and explanation

Correct answer: D — Refer for nephrology assessment and arrange a renal ultrasound scan

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

She has CKD G2 A3, with persistent severe albuminuria despite appropriate renoprotective treatment. Although an ACR of 70 mg/mmol or more does not itself mandate nephrology referral when it is attributable to diabetes and already appropriately treated, that exception does not apply when ACR above 30 mg/mmol coexists with haematuria. NICE advises specialist assessment in this situation. She has also had persistent invisible haematuria: 2 of 3 positive reagent-strip tests supports persistence. NICE recommends renal ultrasound for adults with CKD and persistent invisible haematuria, irrespective of her stable eGFR or low KFRE risk. Therefore, nephrology referral and renal ultrasound should proceed concurrently. B incorrectly applies the diabetes exception while overlooking the separate A3-plus-haematuria referral criterion. C is inappropriate because she is under 60 and has neither dysuria nor a raised white cell count; she does not meet the NICE suspected bladder-cancer pathway threshold for unexplained non-visible haematuria. D delays indicated assessment. E omits ultrasound despite persistent invisible haematuria.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Recommendations (2021; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Haematuria and indications for renal ultrasound (2021; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — Haematuria (2015; updated 2026; checked 15 August 2026) — https://www.nice.org.uk/guidance/NG12/chapter/recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations