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Persistent non-visible haematuria with albuminuria — MSRA MCQ

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HardMicrohematuriaPersistent non-visible haematuria with albuminuriaMSRA

A 62-year-old man presents with 4 weeks of dysuria. He has no visible haematuria, fever, loin pain, urethral discharge, weight loss, recent urinary instrumentation or vigorous exercise. He is a current smoker. Two correctly collected midstream urine specimens, taken 2 weeks apart, show blood 2+ and blood 1+ on reagent-strip testing. Both are negative for nitrites and leucocytes, and cultures show no significant growth. Urine ACR is 48 mg/mmol and 44 mg/mmol on two early-morning samples taken 13 weeks apart. eGFR is stable at 72 mL/min/1.73 m², potassium is 4.3 mmol/L, and blood pressure is 150/92 mmHg despite amlodipine 10 mg daily. He does not have diabetes. Which management plan is most appropriate now?

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

Reveal the answer and explanation

Correct answer: B — Make a suspected cancer pathway referral to urology, refer for nephrology assessment, and add ramipril.

This man requires parallel urological and renal management. He is aged 60 years or over and has unexplained non-visible haematuria with dysuria; negative urine cultures make infection an inadequate explanation. NICE therefore recommends suspected cancer pathway referral for possible bladder cancer. Smoking increases concern but is not needed to meet the referral criterion. He also has persistent albuminuria: ACR remains above 30 mg/mmol on samples more than 3 months apart, alongside persistent haematuria. This fulfils NICE criteria for nephrology referral, irrespective of his preserved eGFR. In addition, he has hypertension with ACR above 30 mg/mmol, for which an ACE inhibitor or ARB should be offered and titrated as tolerated, with appropriate renal function and potassium monitoring. A omits indicated nephrology assessment. B recognises renal disease but incorrectly downgrades the urological referral despite the age-and-dysuria criterion. D delays both indicated renoprotective treatment and nephrology referral; chronicity is already demonstrated. E misses the suspected cancer pathway indication. The referrals should proceed concurrently: evidence of possible glomerular disease does not exclude urinary tract malignancy.

Reference: NICE NG12: Suspected cancer: recognition and referral — Haematuria (2015; updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations NICE NG203: Chronic kidney disease: assessment and management — Referral criteria (2021; current 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Treating hypertension (2021; current 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations