skip to main content

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

Instant feedback + full explanation. One question, done properly.

HardHematuriaPersistent non-visible haematuria with albuminuric chronic kidney diseaseMSRA

A 53-year-old man is reviewed after incidental non-visible haematuria. He has no visible haematuria, dysuria, frequency, fever, loin pain, weight loss, recurrent urinary tract infection or symptoms of urinary obstruction. He has no diabetes. He takes ramipril 10 mg daily for hypertension; his blood pressure is 126/74 mmHg. Three correctly collected midstream urine samples over 4 months show 2+ blood on reagent-strip testing. Nitrites and leucocytes are negative and all cultures show no significant growth. Early-morning urine ACR is 76 mg/mmol. eGFR is 72 mL/min/1.73 m² on two measurements 4 months apart. Full blood count, including white cell count, is normal. What is the most appropriate management plan today?

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

Reveal the answer and explanation

Correct answer: D — Refer for nephrology assessment and arrange renal ultrasound, without a suspected cancer pathway referral at present

This man has persistent invisible haematuria, confirmed by at least 2 positive reagent-strip tests from 3 samples. His ACR of 76 mg/mmol is a marker of kidney damage and does not require confirmation because it is at least 70 mg/mmol. In the context of persistence over more than 3 months, this establishes CKD despite a preserved eGFR. NICE recommends nephrology referral for CKD with ACR of 70 mg/mmol or more. NICE also recommends renal ultrasound for adults with CKD and visible or persistent invisible haematuria. A suspected cancer pathway is not indicated solely from this presentation: unexplained non-visible haematuria requires age 60 years or over plus dysuria or a raised white cell count for bladder cancer referral. He is 53, has neither feature, and has no visible haematuria. Repeating the ACR would be appropriate for a result between 3 and 70 mg/mmol, but not at 76 mg/mmol. Annual surveillance alone is appropriate for persistent isolated invisible haematuria without proteinuria, not for marked albuminuria. CT urography and routine urology referral are not the indicated first pathway here.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer (2015, updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer