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Chronic kidney disease with A3 albuminuria and non-visible haematuria — MSRA MCQ

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HardMicrohematuriaChronic kidney disease with A3 albuminuria and non-visible haematuriaMSRA

A 36-year-old woman is reviewed after incidental non-visible haematuria. She has no visible haematuria, dysuria, urinary frequency, loin pain, fever, rash, arthralgia, recent urinary instrumentation or vigorous exercise. Samples were collected outside menstruation. She does not have diabetes, hypertension or a family history of kidney disease. Three correctly collected midstream urine samples over 3 weeks show blood 2+, negative and blood 1+ on reagent-strip testing. Urine microscopy on the final sample reports no red cells. All urine cultures show no significant growth. Two early-morning urine ACR measurements are 36 mg/mmol and 34 mg/mmol, taken 13 weeks apart. Her eGFR is 102 mL/min/1.73 m², blood pressure is 122/74 mmHg, and potassium is normal. What is the most appropriate next management plan?

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Reveal the answer and explanation

Correct answer: B — Arrange renal ultrasound and refer for nephrology assessment

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

This patient requires renal ultrasound and nephrology referral. Reagent-strip haematuria of 1+ or greater warrants evaluation, and NICE specifically advises against using urine microscopy to confirm or negate a positive reagent-strip result. Thus, the negative microscopy result does not dismiss the repeated positive strip tests. Her ACR is persistently in the A3 range (>30 mg/mmol), despite preserved eGFR. Albuminuria is a marker of kidney damage, so normal filtration does not exclude CKD. NICE recommends specialist 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 insufficient because annual surveillance is recommended for persistent invisible haematuria in the absence of proteinuria; this patient has confirmed A3 albuminuria. C is wrong because microscopy should not be used to confirm a positive reagent-strip result. D is inappropriate: in non-diabetic CKD, ACE inhibitor or ARB treatment is indicated for ACR above 30 mg/mmol when hypertension is present, or at ACR 70 mg/mmol or more irrespective of hypertension; neither applies here. E is not indicated because she does not meet NICE suspected-bladder-cancer criteria for non-visible haematuria, which require age 60 years or over plus dysuria or raised white-cell count.

Reference: Chronic kidney disease: assessment and management (NG203), haematuria recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203), investigation and referral recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203), pharmacotherapy recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations