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Suspected acute nephritis causing acute kidney injury — MSRA MCQ

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HardHematuriaSuspected acute nephritis causing acute kidney injuryMSRA

A 52-year-old woman is reviewed urgently after abnormal blood and urine results. Five days ago, during assessment for new ankle swelling, her serum creatinine was 80 micromol/L. Today it is 144 micromol/L. She reports 4 days of dark urine and mild facial puffiness. She has no dysuria, fever, loin pain, vomiting, diarrhoea, urinary retention, recent urinary catheterisation or NSAID use. Her blood pressure is 168/96 mmHg, pulse is 76 beats/minute and temperature is 36.7°C. Urine dipstick is 3+ blood and 3+ protein, with negative nitrites and leucocytes. A correctly collected midstream urine culture shows no significant growth. Potassium is 4.8 mmol/L and she has no breathlessness or features of fluid overload. What is the most appropriate management in the next 24 hours?

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Correct answer: C — Discuss urgently with nephrology for suspected acute nephritis causing acute kidney injury

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

This woman has acute kidney injury: her creatinine has risen from 80 to 144 micromol/L within 5 days, an increase of more than 50%. The combination of AKI without an evident pre-renal, septic, obstructive, drug-related or catheter-related cause, together with sterile haematuria and substantial proteinuria, should prompt suspicion of acute nephritis/glomerulonephritis. Her new hypertension and oedema further support a glomerular process. NICE advises nephrology discussion as soon as possible, and within 24 hours, where AKI has no clear cause or where glomerulonephritis is a possible diagnosis. A is initially attractive because she has visible haematuria and is over 45; however, the immediate priority is suspected intrinsic renal disease with AKI, rather than a urological cancer pathway. B risks an unsafe delay in potentially treatable glomerulonephritis. C is not supported because there are no infective symptoms, pyuria, nitrites or significant culture growth. D may form part of subsequent AKI investigation if obstruction is suspected, but imaging should not delay nephrology input when acute nephritis is suspected.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management (2024) — https://www.nice.org.uk/guidance/ng148/resources/acute-kidney-injury-prevention-detection-and-management-pdf-66141786535621