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Albuminuric chronic kidney disease with persistent invisible haematuria — MSRA MCQ

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HardHematuriaAlbuminuric chronic kidney disease with persistent invisible haematuriaMSRA

A 57-year-old woman has reagent-strip haematuria detected during routine hypertension review. She has no visible haematuria, dysuria, urinary frequency, fever, loin pain, weight loss, vaginal bleeding or recent urinary instrumentation. She does not smoke. Three correctly collected midstream urine samples over 5 weeks each show 2+ blood. Nitrites and leucocytes are negative, and urine cultures show no significant growth. Her white cell count is 7.2 × 10⁹/L. Two early-morning urine ACR measurements, taken 4 months apart, are 42 mg/mmol and 47 mg/mmol. Her eGFR is 68 mL/min/1.73 m² on both occasions and her blood pressure is 132/78 mmHg. What is the most appropriate management plan today?

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

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Correct answer: B — Refer for specialist renal assessment and offer renal ultrasonography

Explanation lettering: C = shown as B · B = shown as C

This is persistent invisible haematuria because at least 2 of 3 reagent-strip tests are positive. She also has persistent A3 albuminuria: both early-morning ACR measurements exceed 30 mg/mmol and are separated by more than 3 months, establishing CKD despite preserved eGFR. NICE recommends specialist renal assessment for CKD when ACR exceeds 30 mg/mmol in combination with haematuria. NICE also recommends renal ultrasound for adults with CKD and persistent invisible haematuria. A is inappropriate because the NICE suspected cancer pathway criterion for unexplained non-visible haematuria requires age 60 years or over plus dysuria or a raised white cell count; she fulfils none of these additional criteria. B applies to persistent invisible haematuria in the absence of proteinuria or albuminuria, but misses the renal referral threshold in this case. D is plausible because structural urological disease remains possible and ultrasound is indicated, but the stated findings establish a nephrology referral criterion; there is no specified urological obstruction, visible haematuria or cancer-pathway indication. E delays referral despite already confirmed persistent haematuria and albuminuria.

Reference: NICE NG203: Chronic kidney disease: assessment and management, recommendations 1.1.17 to 1.1.19, 1.2.5 and 1.5.5 (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral, recommendation 1.6.4 (2015, current NICE page checked August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer