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Chronic kidney disease with persistent invisible haematuria — MSRA MCQ

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HardNephrologyChronic kidney disease with persistent invisible haematuriaMSRA

A 61-year-old man is reviewed following annual CKD monitoring. His eGFR has been 54, 52 and 53 mL/min/1.73 m² over 10 months. Two early-morning urine ACR measurements, 4 months apart, are 12 mg/mmol and 14 mg/mmol. He takes ramipril for hypertension and has no diabetes. Urine dipstick at both reviews shows blood 2+ and protein 1+. Urine microscopy confirms red cells; urine cultures are negative. He has no dysuria, visible haematuria, urinary frequency, loin pain, hesitancy or reduced stream. His full blood count is normal. BP is 126/72 mmHg, potassium is 4.5 mmol/L, and his laboratory-reported 5-year Kidney Failure Risk Equation risk is 1.6%. Which is the most appropriate next investigation?

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

Reveal the answer and explanation

Correct answer: B — Arrange a renal ultrasound scan

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

He has established CKD G3a with persistent invisible haematuria: blood has been present on two separated urine samples, with microscopy-confirmed red cells and negative cultures. NICE recommends renal ultrasound for all adults with CKD who have visible or persistent invisible haematuria. This is therefore the appropriate next investigation. A is inadequate because persistent haematuria requires investigation rather than routine annual surveillance. B is not the recommended first renal investigation in this context; urine cytology has limited utility as an initial test for asymptomatic microscopic haematuria. C is plausible because haematuria may suggest intrinsic renal disease, but he does not meet NICE CKD referral criteria: his ACR is below 30 mg/mmol, kidney function is stable, his 5-year KFRE risk is below 5%, and hypertension is controlled. E is inappropriate: ACE inhibitors can alter creatinine and potassium, but do not explain persistent urinary red cells; ramipril remains indicated for hypertension and albuminuria unless another contraindication develops.

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