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Suspected acute nephritis causing unexplained acute kidney injury — MSRA MCQ

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ModerateNephrologySuspected acute nephritis causing unexplained acute kidney injuryMSRA

A 46-year-old woman is reviewed urgently after an abnormal blood test requested for 5 days of fatigue and nausea. She has no previous kidney disease. Five days ago, her creatinine was 78 micromol/L during a pre-employment medical; today it is 142 micromol/L. Potassium is 4.8 mmol/L and bicarbonate is 24 mmol/L. She is afebrile, clinically euvolaemic and has a BP of 148/88 mmHg. She has had no vomiting, diarrhoea, fever, recent contrast exposure, NSAID use or new prescribed medicines. She has no dysuria, visible haematuria, loin pain, hesitancy or reduced urinary stream. Urine dipstick shows blood 3+ and protein 2+, with negative leucocytes and nitrites. A urine culture is subsequently negative. What is the most appropriate next management step?

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Correct answer: B — Discuss the acute kidney injury with nephrology as soon as possible and within 24 hours

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

This patient has acute kidney injury (AKI): creatinine has risen by more than 50% within 7 days. There is no convincing pre-renal, drug-related, infective or obstructive explanation. The combination of AKI, haematuria and proteinuria without urinary infection should prompt suspicion of acute nephritis/glomerulonephritis. NICE advises nephrology discussion as soon as possible and within 24 hours when AKI has no clear cause or a potentially specialist-treated diagnosis, including glomerulonephritis. A is inappropriate because a 48-hour watch-and-wait approach risks delaying assessment of potentially rapidly progressive glomerular disease. B is attractive because NICE advises ultrasound within 24 hours for AKI with no identified cause or obstruction risk; however, imaging should not precede or delay nephrology input where the urinalysis suggests acute nephritis. D is inappropriate because immunosuppression requires specialist assessment and diagnostic work-up, often including serology and consideration of biopsy. E is too slow for unexplained AKI with a nephritic urine dipstick pattern.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management — Recommendations (2019, updated 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG148: Acute kidney injury: prevention, detection and management — Urinalysis recommendation 1.4.3 (2019, updated 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG148: Acute kidney injury: prevention, detection and management — Nephrology discussion recommendation 1.5.15 (2019, updated 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations