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Persistent isolated non-visible haematuria — MSRA MCQ

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HardMicrohematuriaPersistent isolated non-visible haematuriaMSRA

A 54-year-old man has incidental non-visible haematuria identified during an employment medical. He has no visible haematuria, dysuria, frequency, loin pain, fever, weight loss, recent urinary instrumentation or vigorous exercise. He stopped smoking 8 years ago. Three correctly collected midstream urine specimens over 14 weeks show blood 2+, blood 1+ and negative on reagent-strip testing. Nitrites and leucocytes are negative, and all cultures show no significant growth. Urine microscopy on the most recent specimen reports no red cells. Two early-morning urine ACR measurements are 1.1 mg/mmol and 1.3 mg/mmol. His eGFR is stable at 76 mL/min/1.73 m², blood pressure is 126/78 mmHg 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: E — Arrange renal ultrasound and continue annual monitoring of haematuria, ACR, eGFR and blood pressure

This is persistent invisible haematuria: 2 of 3 reagent-strip tests are positive. NICE advises using reagent strips for haematuria and specifically advises against using urine microscopy to confirm a positive result; therefore, the negative microscopy result does not negate the finding. The abnormality has persisted for more than 3 months and represents a marker of kidney damage despite preserved G2 eGFR and normal ACR. NICE recommends renal ultrasound for adults with CKD who have persistent invisible haematuria. In the absence of proteinuria, ongoing annual monitoring of haematuria, albuminuria, eGFR and blood pressure is also recommended while haematuria persists. A suspected cancer pathway referral is not indicated by NICE NG12 here: non-visible haematuria requires age 60 years or over plus dysuria or a raised white cell count. Nephrology referral is not required solely for isolated haematuria with stable renal function and ACR below 30 mg/mmol. Repeating microscopy is unnecessary, and discharge would omit both indicated imaging and surveillance.

Reference: NICE NG203: Chronic kidney disease: assessment and management — haematuria recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — follow-up and renal ultrasound (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG12: Suspected cancer: recognition and referral — haematuria (2015, current page checked 16 August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommended-actions-organised-by-symptom-and-findings-of-primary-care-investigations