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CKD G3a A2 with persistent invisible haematuria — MSRA MCQ

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ModerateNephrologyCKD G3a A2 with persistent invisible haematuriaMSRA

A 47-year-old woman is reviewed in general practice following abnormal results on occupational health screening. She has hypertension treated with amlodipine 5 mg once daily. She does not have diabetes and is clinically euvolaemic. She has no dysuria, loin pain, visible haematuria, lower urinary tract symptoms, fever, rash or joint symptoms. She has not used NSAIDs and has no family history of kidney disease. Her eGFR was 56 mL/min/1.73 m² 4 months ago and is now 54 mL/min/1.73 m². Two early-morning urine ACR measurements, taken 3 months apart, are 18 mg/mmol and 21 mg/mmol. Urine dipstick is positive for blood 2+ on both occasions. Midstream urine culture is negative. Her laboratory-reported 5-year Kidney Failure Risk Equation risk is 1.1%. What is the most appropriate management plan now?

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Correct answer: A — Arrange renal ultrasound and continue CKD monitoring in primary care unless another referral criterion emerges

She has established CKD G3a A2: eGFR has remained below 60 mL/min/1.73 m² for more than 3 months and ACR is persistently 3–30 mg/mmol. Persistent invisible haematuria is a NICE indication for renal ultrasound in adults with CKD, to help establish a potentially treatable structural cause. Her low 5-year kidney failure risk does not remove this imaging indication. Routine nephrology referral is not currently indicated. NICE recommends specialist assessment for ACR above 30 mg/mmol with haematuria, ACR of at least 70 mg/mmol (subject to the diabetes exception), kidney failure risk above 5%, accelerated eGFR decline, resistant hypertension, or suspected specific renal disease. Her ACR is A2, kidney function is stable, and her KFRE is 1.1%. Urgent nephrology referral would be appropriate if there were an acute nephritic presentation or otherwise unexplained AKI with blood and protein on dipstick, neither of which is present. Annual monitoring alone misses the need to investigate persistent haematuria. Routine urology referral is not automatically required solely on these findings; renal ultrasound is the specified CKD investigation.

Reference: Chronic kidney disease: assessment and management (NG203) — Recommendations (Published August 2021; last updated November 2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203) — Referral criteria (Published August 2021; last updated November 2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Acute kidney injury: prevention, detection and management (NG148) — Urinalysis (Published August 2019) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations