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Chronic kidney disease with persistent invisible haematuria and A3 albuminuria — MSRA MCQ

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HardMicrohematuriaChronic kidney disease with persistent invisible haematuria and A3 albuminuriaMSRA

A 55-year-old man with hypertension attends after incidental non-visible haematuria. He has no visible haematuria, dysuria, frequency, loin pain, fever, weight loss, urinary tract infection symptoms, recent urinary instrumentation or vigorous exercise. He has never smoked. He takes losartan 100 mg daily; blood pressure is 128/76 mmHg and potassium is normal. Three correctly collected early-morning urine samples over 4 months show blood 2+, negative and blood 1+ on reagent-strip testing. All midstream urine cultures show no significant growth. Urine ACR is 44 mg/mmol and 47 mg/mmol on samples taken 13 weeks apart. eGFR is stable at 74 mL/min/1.73 m². Full blood count is normal. What is the most appropriate next management step?

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Correct answer: A — Refer for nephrology assessment and arrange a renal ultrasound scan

This man has persistent invisible haematuria: two of three reagent-strip tests are positive at 1+ or greater. He also has persistent A3 albuminuria, with ACR above 30 mg/mmol on two samples separated by more than 3 months, establishing CKD despite a preserved eGFR. NICE recommends nephrology referral for CKD with ACR above 30 mg/mmol together with haematuria. NICE also recommends renal ultrasound for all adults with CKD who have persistent invisible haematuria. A suspected cancer pathway referral is not indicated by NG12 in this presentation: non-visible haematuria requires age 60 years or over plus either dysuria or a raised white cell count for the bladder cancer criterion. Annual surveillance is appropriate for persistent isolated invisible haematuria without proteinuria, not for haematuria with confirmed A3 albuminuria. Adding an ACE inhibitor to an ARB is inappropriate because dual renin–angiotensin system blockade should not be used; he is already on a maximally dosed ARB. Urine microscopy is not required to confirm a positive reagent-strip result in adults.

Reference: NICE NG203: Chronic kidney disease: assessment and management — haematuria, ultrasound and referral criteria (2021; page current and crawled 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — bladder cancer recommendation 1.6.4 (2015, amended 2025; page current and crawled 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer