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Persistent invisible haematuria with A3 albuminuria — MSRA MCQ

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ModerateMicrohematuriaPersistent invisible haematuria with A3 albuminuriaMSRA

A 47-year-old woman has incidental non-visible haematuria identified during a routine health assessment. She has no dysuria, urinary frequency, loin pain, fever, visible haematuria, weight loss, recent urinary instrumentation or vigorous exercise. Samples were collected outside menstruation. She does not smoke and has no diabetes. Urine reagent-strip testing on three correctly collected early-morning samples over 4 months shows blood 2+, blood 1+ and blood 2+. All midstream urine cultures show no significant growth. Urine ACR is 34 mg/mmol and 38 mg/mmol on early-morning samples taken 13 weeks apart. Her eGFR is stable at 96 mL/min/1.73 m² and blood pressure is 122/74 mmHg. 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: B — Arrange renal ultrasound and refer for nephrology assessment

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

This woman has persistent invisible haematuria: at least 2 of 3 reagent-strip tests are positive. She also has persistent A3 albuminuria, with ACR values above 30 mg/mmol on samples more than 3 months apart. NICE recommends specialist assessment for adults with CKD when ACR is more than 30 mg/mmol together with haematuria, even when eGFR and blood pressure are normal. NICE also recommends renal ultrasound for adults with CKD who have persistent invisible haematuria. A is appropriate for persistent isolated invisible haematuria without proteinuria, but not when A3 albuminuria is present. C is incorrect because she does not meet the NICE suspected bladder cancer threshold for non-visible haematuria: this requires age 60 years or over plus dysuria or a raised white cell count. D is not the appropriate primary-care treatment threshold in a non-diabetic adult with ACR below 70 mg/mmol; the referral criterion takes priority. E is incorrect because NICE advises reagent-strip testing for haematuria and specifically advises against urine microscopy to confirm a positive dipstick result.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — Urological cancers (2015, amended 2025) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer