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Persistent isolated non-visible haematuria — MSRA MCQ

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HardMicrohematuriaPersistent isolated non-visible haematuriaMSRA

A 58-year-old man has non-visible haematuria detected during an insurance medical. He has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss, urinary tract infection symptoms, recent instrumentation or vigorous exercise. He is a former smoker. Three correctly collected midstream urine samples over 14 weeks show blood 2+, negative and blood 1+ on reagent-strip testing. Nitrites and leucocytes are negative and all cultures show no significant growth. Urine microscopy from the final specimen reports no red cells. Two early-morning urine ACR measurements are 1.1 mg/mmol and 1.3 mg/mmol. eGFR is stable at 94 mL/min/1.73 m², blood pressure is 124/76 mmHg and full blood count is normal. What is the most appropriate next management step?

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

Reveal the answer and explanation

Correct answer: A — Arrange annual monitoring of haematuria, ACR, eGFR and blood pressure while haematuria persists

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

This is persistent isolated invisible haematuria: two of three appropriately collected reagent-strip tests are positive at 1+ or greater. NICE advises using reagent strips for haematuria assessment and specifically advises against using urine microscopy to confirm a positive dipstick result. Therefore, the microscopy report of no red cells does not overturn the confirmed persistent dipstick haematuria. He has no albuminuria, impaired renal function, hypertension or other evidence suggesting glomerular disease. He also does not meet NICE suspected-cancer-pathway criteria for non-visible haematuria because he is under 60 and has neither dysuria nor a raised white cell count. Former smoking status may increase clinical concern but does not replace the specified referral threshold. In persistent invisible haematuria without proteinuria, NICE recommends annual repeat testing for haematuria, proteinuria/albuminuria, GFR and blood pressure for as long as it persists. A is therefore premature. B would be indicated for persistent invisible haematuria in an adult with established CKD, but this man has normal eGFR and ACR. C contradicts NICE guidance on confirmation. D would be appropriate with ACR above 30 mg/mmol plus haematuria, significant renal impairment or another renal referral criterion.

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