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Persistent non-visible haematuria with albuminuria — MSRA MCQ

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HardMicrohematuriaPersistent non-visible haematuria with albuminuriaMSRA

A 34-year-old woman has incidental non-visible haematuria identified during a pre-employment medical. She has no dysuria, frequency, loin pain, fever, visible haematuria, weight loss, urinary tract infection symptoms, recent instrumentation or vigorous exercise. Samples were collected outside menstruation. She does not smoke and takes no regular medication. Three correctly collected early-morning urine samples over 16 weeks show blood 2+, blood negative and blood 1+ on reagent strip. All midstream urine cultures show no significant growth. Urine ACR is 42 mg/mmol and 46 mg/mmol on early-morning samples taken 14 weeks apart. Her eGFR is stable at 102 mL/min/1.73 m², blood pressure is 118/72 mmHg and full blood count is normal. She does not have diabetes. 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: C — Refer for nephrology assessment and arrange renal ultrasound while continuing CKD monitoring

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

This woman has persistent invisible haematuria because 2 of 3 appropriately collected reagent-strip samples are positive at 1+ or greater. She also has confirmed A3 albuminuria: both early-morning ACR results are above 30 mg/mmol and are separated by more than 3 months. This establishes a renal abnormality despite preserved eGFR and normal blood pressure. NICE recommends specialist assessment for adults with CKD who have ACR above 30 mg/mmol together with haematuria. NICE also recommends renal ultrasound for adults with CKD and persistent invisible haematuria. Therefore, nephrology referral with renal ultrasound is the appropriate plan. A is incorrect because she does not meet NICE suspected bladder cancer criteria for non-visible haematuria: she is under 60 years and has neither dysuria nor a raised white cell count. B is attractive because albuminuria can prompt RAAS blockade, but in non-diabetic CKD with ACR 30–70 mg/mmol and no hypertension, NICE advises monitoring rather than routine ACE inhibitor or ARB initiation. C would be appropriate for isolated persistent invisible haematuria without proteinuria, but misses the referral threshold created by concomitant A3 albuminuria. E is incorrect because NICE advises against using urine microscopy to confirm a positive haematuria reagent-strip result.

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 — Renal ultrasound and referral criteria (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Managing proteinuria (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations