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Chronic kidney disease with persistent invisible haematuria — MSRA MCQ

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HardMicrohematuriaChronic kidney disease with persistent invisible haematuriaMSRA

A 48-year-old man with type 2 diabetes and hypertension attends for review. He has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss, recent urinary instrumentation or vigorous exercise. Blood pressure is 126/74 mmHg. His eGFR is 56 mL/min/1.73 m² and 54 mL/min/1.73 m² on samples taken 3 months apart. Early-morning urine ACR is 1.8 mg/mmol and 2.1 mg/mmol. Three correctly collected midstream urine samples over 10 weeks show blood 1+, blood 2+ and negative on reagent-strip testing. Nitrites and leucocytes are negative and all cultures show no significant growth. Full blood count is normal. His 5-year Kidney Failure Risk Equation result is 1.1%. What is the most appropriate next investigation?

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

Reveal the answer and explanation

Correct answer: D — Arrange a renal ultrasound scan.

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

He has CKD because eGFR has remained below 60 mL/min/1.73 m² for at least 3 months. He also has persistent invisible haematuria: two of three dipsticks are positive at 1+ or greater. NICE recommends renal ultrasound for all adults with CKD who have visible or persistent invisible haematuria. B is not indicated by NG12: non-visible haematuria prompts a bladder suspected-cancer referral only in people aged 60 years or over with dysuria or a raised white cell count. C is not the best next step because he has no stated nephrology referral criterion: his ACR is not above 30 mg/mmol with haematuria, there is no accelerated eGFR decline, and his 5-year kidney failure risk is low. D is incorrect because NICE advises using reagent strips for haematuria and not using urine microscopy to confirm a positive result. E would be appropriate only after indicated investigation; annual surveillance alone would miss the recommended ultrasound assessment in CKD with persistent invisible haematuria.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Haematuria and indications for renal ultrasound (2021; checked 16 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/recommendations NICE NG203: Chronic kidney disease: assessment and management — Referral criteria (2021; checked 16 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/recommendations NICE NG12: Suspected cancer: recognition and referral — Bladder cancer (2015; last updated April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer