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Chronic kidney disease with persistent non-visible haematuria — MSRA MCQ

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HardHematuriaChronic kidney disease with persistent non-visible haematuriaMSRA

A 63-year-old man has incidental non-visible haematuria during review of hypertension. He has never had visible haematuria and has no dysuria, frequency, loin pain, fever, weight loss or urinary retention. Urine dipstick is 2+ for blood on two of three correctly collected samples over 4 months. Urine cultures show no significant growth. Early-morning urine ACR is 14 mg/mmol and 16 mg/mmol on repeat testing. His eGFR is 56 mL/min/1.73 m² and 54 mL/min/1.73 m² on repeat testing after 4 months. Blood pressure is 132/78 mmHg, and full blood count is normal, including a white cell count of 7.1 × 10⁹/L. What is the most appropriate next investigation?

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Correct answer: C — Arrange a renal ultrasound scan

He has chronic kidney disease: eGFR is below 60 mL/min/1.73 m² on measurements separated by more than 3 months, and he has confirmed albuminuria. He also has persistent invisible haematuria, established by at least 2 positive reagent-strip tests out of 3. NICE recommends renal ultrasound for all adults with CKD who have visible or persistent invisible haematuria. Therefore, renal ultrasound is the appropriate next investigation. Annual surveillance alone is recommended for persistent invisible haematuria in the absence of proteinuria; this patient has confirmed albuminuria and CKD. A suspected cancer pathway referral for bladder cancer is not indicated: non-visible haematuria requires age 60 years or over plus dysuria or a raised white cell count, neither of which is present. Routine nephrology referral is not required solely for ACR 14–16 mg/mmol with stable G3a CKD; the relevant referral threshold is ACR above 30 mg/mmol together with haematuria. Non-contrast CT KUB would be appropriate when stone disease is clinically suspected, but he has no colic or other features suggesting calculi.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Haematuria and indications for renal ultrasound (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Referral criteria (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — Bladder cancer recommendation 1.6.4 (2015) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer