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Persistent invisible haematuria with A3 albuminuria and hyperkalaemia — MSRA MCQ

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HardMicrohematuriaPersistent invisible haematuria with A3 albuminuria and hyperkalaemiaMSRA

A 47-year-old woman with hypertension attends after non-visible haematuria was found during a routine review. She has no visible haematuria, dysuria, frequency, loin pain, fever, rash, arthralgia, recent urinary instrumentation or vigorous exercise. Samples were collected outside menstruation. She does not have diabetes. Three correctly collected early-morning urine samples over 4 months show blood 2+, negative and blood 1+ on reagent-strip testing. Urine cultures show no significant growth. Urine ACR is 52 mg/mmol and 49 mg/mmol on samples taken 13 weeks apart. Her eGFR is stable at 91 mL/min/1.73 m². Blood pressure is 148/92 mmHg despite amlodipine 10 mg daily. Potassium is 5.3 mmol/L on two non-haemolysed samples. Full blood count is normal. 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: D — Refer for nephrology assessment, withhold ACE inhibitor or ARB treatment pending assessment and correction of hyperkalaemia, and optimise blood pressure without renin–angiotensin system blockade

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

This patient has persistent invisible haematuria because 2 of 3 reagent-strip tests are positive. She also has persistent A3 albuminuria, demonstrated on early-morning samples more than 3 months apart. An ACR above 30 mg/mmol together with haematuria is a NICE criterion for nephrology referral, irrespective of her preserved eGFR. Her hypertension and ACR above 30 mg/mmol would ordinarily indicate an ACE inhibitor or ARB; however, NICE advises against routinely starting a renin–angiotensin system antagonist when pretreatment potassium exceeds 5.0 mmol/L. Her confirmed potassium of 5.3 mmol/L therefore requires assessment and correction before such treatment is considered. A and B are inappropriate because both ACE inhibitors and ARBs can worsen hyperkalaemia; choosing an ARB does not circumvent this precaution. C is not indicated: she is under 60, has no dysuria or raised white-cell count, and does not meet NICE criteria for a bladder cancer suspected cancer pathway referral for non-visible haematuria. E applies to persistent isolated invisible haematuria without proteinuria after appropriate malignancy consideration, but her A3 albuminuria is the important exception requiring renal specialist assessment.

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