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Persistent non-visible haematuria with albuminuric chronic kidney disease — MSRA MCQ

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HardMicrohematuriaPersistent non-visible haematuria with albuminuric chronic kidney diseaseMSRA

A 39-year-old man with hypertension attends after incidental non-visible haematuria. He has no visible haematuria, dysuria, frequency, loin pain, fever, weight loss, recent urinary instrumentation or vigorous exercise. He does not have diabetes. Three correctly collected early-morning urine samples over 4 months show blood 2+, negative and blood 1+ on reagent-strip testing. Urine cultures show no significant growth. Urine ACR is 46 mg/mmol and 42 mg/mmol on early-morning samples taken 13 weeks apart. His eGFR is 75 mL/min/1.73 m² on both occasions, potassium is 4.2 mmol/L, and blood pressure is 146/92 mmHg despite amlodipine 10 mg daily. Which management plan is most appropriate now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Add an ACE inhibitor, arrange renal ultrasound, and refer for nephrology assessment

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

This patient has persistent invisible haematuria: 2 of 3 reagent-strip tests are positive at 1+ or greater. Urine microscopy is not required to confirm this. His ACR is persistently above 30 mg/mmol on samples more than 3 months apart, establishing albuminuric CKD despite preserved eGFR. In an adult with CKD, ACR above 30 mg/mmol together with haematuria is an indication for nephrology referral. Persistent invisible haematuria in CKD also warrants renal ultrasound. His hypertension with ACR above 30 mg/mmol is an additional indication to offer an ACE inhibitor or ARB, titrated as tolerated; potassium and renal function should be checked after initiation. Therefore, these actions should occur in parallel. A is wrong because the ACR has already been confirmed and annual monitoring alone misses the nephrology-referral threshold. B is wrong because microscopy should not be used to confirm dipstick haematuria and it again omits indicated treatment and referral. C omits renal ultrasound and nephrology assessment. D includes appropriate treatment and imaging, but urology referral is not the specified pathway here: at age 39 without visible haematuria, dysuria or raised white cell count, he does not meet the NICE suspected-bladder-cancer referral criteria. The dominant referral indication is renal.

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 — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations