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Persistent non-visible haematuria with CKD — MSRA MCQ

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ModerateMicrohematuriaPersistent non-visible haematuria with CKDMSRA

A 55-year-old man has non-visible haematuria detected during a hypertension review. He has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss, recent urinary instrumentation or vigorous exercise. He does not smoke. Blood pressure is 128/76 mmHg on amlodipine. Three correctly collected midstream urine samples over 4 months show blood 2+, negative and blood 1+ on reagent-strip testing. Urine cultures show no significant growth. Early-morning urine ACR measurements are 30 mg/mmol and 29 mg/mmol, taken 13 weeks apart. His eGFR is 72 mL/min/1.73 m² on both occasions. Full blood count is normal. What is the most appropriate next investigation?

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Correct answer: A — Arrange a renal ultrasound scan

He has persistent invisible haematuria because 2 of 3 reagent-strip tests are positive. His ACR is persistently abnormal, establishing CKD despite preserved eGFR. NICE recommends renal ultrasound for all adults with CKD who have visible or persistent invisible haematuria; this is therefore the appropriate next investigation. A nephrology referral is not yet indicated solely on these findings. The relevant NICE referral threshold is an ACR of more than 30 mg/mmol together with haematuria; an ACR of exactly 30 mg/mmol does not meet that criterion. A suspected cancer pathway referral for bladder cancer is not indicated because non-visible haematuria requires age 60 years or over plus dysuria or a raised white cell count. He is 55 years old, has neither feature and has no visible haematuria. Annual surveillance is appropriate for persistent isolated invisible haematuria after appropriate assessment, but does not replace ultrasound in a person with CKD and persistent haematuria. Urine microscopy should not be used to confirm a positive reagent-strip result in this setting.

Reference: NICE NG203: Chronic kidney disease: assessment and management, recommendations 1.1.16-1.1.19 (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management, recommendation 1.2.5 (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management, recommendation 1.5.5 (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations