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Persistent non-visible haematuria with albuminuria and unexplained neutrophilia — MSRA MCQ

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HardMicrohematuriaPersistent non-visible haematuria with albuminuria and unexplained neutrophiliaMSRA

A 68-year-old woman is reviewed after non-visible haematuria was identified during an insurance medical. She has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss, vaginal bleeding, recent urinary instrumentation or vigorous exercise. Samples were collected outside menstruation. She has never smoked. Three correctly collected midstream urine samples over 4 weeks show blood 2+, negative and blood 1+ on reagent-strip testing. Nitrites and leucocytes are negative on each sample, and all urine cultures show no significant growth. Two early-morning urine ACR measurements are 46 mg/mmol and 49 mg/mmol, taken 13 weeks apart. Her eGFR is stable at 82 mL/min/1.73 m², blood pressure is 126/74 mmHg and potassium is normal. Full blood count shows a white cell count of 12.7 × 10⁹/L with neutrophilia, rising to 13.1 × 10⁹/L on repeat testing 3 weeks later. She remains systemically well and there is no clinical focus of infection. What is the most appropriate next management plan?

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Correct answer: C — Arrange a suspected cancer pathway referral for bladder cancer and refer for specialist nephrology assessment

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

This patient requires parallel referral. She has persistent invisible haematuria because 2 of 3 reagent-strip tests are positive. At age 68, unexplained non-visible haematuria with a raised white cell count meets NICE NG12 criteria for a suspected cancer pathway referral for bladder cancer; dysuria is not required when the white cell count is raised. Negative cultures and absence of an infective focus support the description of both findings as unexplained. She also has confirmed A3 albuminuria (ACR above 30 mg/mmol on repeat early-morning testing) with haematuria. NICE CKD guidance recommends specialist nephrology assessment for ACR above 30 mg/mmol together with haematuria, irrespective of her preserved eGFR and controlled blood pressure. Albuminuria suggesting possible glomerular disease does not remove the need to investigate an age-appropriate urological malignancy pathway. B misses the renal referral criterion. C wrongly treats likely renal disease as excluding bladder-cancer investigation. D delays two indicated referrals. E is incorrect because NICE recommends evaluating reagent-strip haematuria of 1+ or greater and does not recommend urine microscopy to confirm a positive reagent-strip result.

Reference: NICE NG12: Suspected cancer: recognition and referral — Bladder cancer, recommendation 1.6.4 (2015; current NICE guidance page checked 16 August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer NICE NG203: Chronic kidney disease: assessment and management — Haematuria and referral criteria (2021; current NICE guidance page checked 16 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations