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Persistent invisible haematuria with severe albuminuria — MSRA MCQ

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HardMicrohematuriaPersistent invisible haematuria with severe albuminuriaMSRA

A 59-year-old man is reviewed after incidental non-visible haematuria. He has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss, recent urinary instrumentation or vigorous exercise. He has never smoked and has no diabetes or hypertension. Three correctly collected midstream urine samples over 4 months show blood 1+, negative and blood 2+ on reagent-strip testing. Nitrites and leucocytes are negative and all cultures show no significant growth. A single early-morning urine ACR is 74 mg/mmol. His eGFR is stable at 82 mL/min/1.73 m², blood pressure is 128/76 mmHg, potassium is 4.4 mmol/L and full blood count is normal. What is the most appropriate next management plan?

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

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Correct answer: A — Arrange renal ultrasound, refer for nephrology assessment, and offer an ACE inhibitor or ARB titrated to the highest tolerated licensed dose.

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

This man has persistent invisible haematuria: two of three reagent-strip tests are positive. Microscopy is not required to confirm a positive dipstick. His ACR of 74 mg/mmol is clinically important albuminuria and does not require confirmation because the initial value is at least 70 mg/mmol. Together with persistent haematuria, this establishes CKD despite preserved eGFR. NICE recommends renal ultrasound for adults with CKD and persistent invisible haematuria. In an adult without diabetes, ACR of 70 mg/mmol or more warrants nephrology assessment and treatment with an ACE inhibitor or ARB, even where blood pressure is normal. Baseline potassium is acceptable for initiating treatment, with subsequent renal-function and potassium monitoring required in practice. A is inappropriate because annual surveillance alone applies to persistent invisible haematuria without proteinuria. B is attractive because haematuria can indicate malignancy, but he does not meet the NICE suspected-cancer threshold for non-visible haematuria: he is under 60 and has neither dysuria nor raised white cell count. D incorrectly applies the less intensive approach used for ACR above 30 but below 70 mg/mmol. E is wrong because ACR at least 70 mg/mmol needs no confirmatory sample, and urine microscopy should not be used to confirm dipstick haematuria.

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