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Persistent invisible haematuria with CKD G3a — MSRA MCQ

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ModerateMicrohematuriaPersistent invisible haematuria with CKD G3aMSRA

A 49-year-old woman is found to have non-visible haematuria during a hypertension review. She has no visible haematuria, dysuria, frequency, loin pain, fever, weight loss, urinary tract infection symptoms, recent urinary instrumentation or vigorous exercise. Samples were collected outside menstruation. Three correctly collected urine samples over 4 months show blood 1+, negative and blood 2+ on reagent-strip testing. Midstream urine cultures show no significant growth. Urine ACR is 1.4 mg/mmol. Her eGFR is 54 mL/min/1.73 m² and 52 mL/min/1.73 m² on repeat testing 4 months later. Blood pressure is 128/76 mmHg on amlodipine. Full blood count is normal. What is the most appropriate next investigation?

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Correct answer: A — Arrange a renal ultrasound scan

This patient has persistent invisible haematuria: 2 of 3 reagent-strip tests are positive at 1+ or greater. She also has confirmed CKD, with eGFR values in the G3a range on tests more than 3 months apart. NICE recommends renal ultrasound for adults with CKD who have visible or persistent invisible haematuria. This is therefore the appropriate next investigation to assess for structural renal tract disease. A suspected cancer pathway referral is not indicated by NICE NG12: non-visible haematuria requires age 60 years or over plus either dysuria or a raised white cell count to meet the bladder-cancer referral criterion. She is 49 years old, asymptomatic and has a normal white cell count. Routine nephrology referral is not currently mandated: she has neither ACR above 30 mg/mmol with haematuria, ACR of 70 mg/mmol or more, accelerated eGFR decline, nor another listed referral criterion. Urine microscopy should not be used to confirm a positive reagent-strip result. Annual surveillance is appropriate for persistent isolated invisible haematuria, but does not replace the indicated initial renal ultrasound in a person with CKD.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — 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 (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer