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Persistent isolated invisible haematuria — MSRA MCQ

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ModerateHematuriaPersistent isolated invisible haematuriaMSRA

A 62-year-old man has incidental non-visible haematuria during an NHS Health Check. He has never noticed visible haematuria and has no dysuria, frequency, urgency, loin pain, fever, weight loss or recurrent urinary tract infection. Reagent-strip testing of 3 correctly collected midstream urine samples over 4 months shows 1+ blood on 2 samples. All urine cultures show no significant growth. His blood pressure is 126/74 mmHg. eGFR is 82 mL/min/1.73 m² on two measurements 4 months apart. An early-morning urine ACR is 1.8 mg/mmol. Full blood count is normal, including a white cell count of 6.9 × 10⁹/L. What is the most appropriate next management plan?

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Correct answer: E — Arrange annual monitoring of haematuria, urine ACR, eGFR and blood pressure while haematuria persists

This is persistent isolated invisible haematuria: 2 of 3 reagent-strip tests are positive, while urine ACR, renal function and blood pressure are normal. NICE advises annual follow-up with repeat testing for haematuria, albuminuria/proteinuria, GFR and blood pressure when persistent invisible haematuria occurs without proteinuria. A suspected cancer pathway referral is not indicated solely because he is over 60. For unexplained non-visible haematuria, NICE NG12 requires age 60 or over plus either dysuria or a raised white cell count; neither is present. Routine upper-tract imaging is therefore not the indicated next step under the suspected-cancer criteria. Nephrology referral is also not warranted: NICE recommends specialist assessment for ACR above 30 mg/mmol with haematuria, among other criteria, none of which apply here. Urine microscopy is not required to confirm a positive reagent-strip result, as NICE recommends evaluating reagent-strip haematuria of 1+ or greater without confirmatory microscopy.

Reference: NICE NG203: Chronic kidney disease: assessment and management, haematuria and 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, current page checked 15 August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer