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Persistent non-visible haematuria with albuminuria and unexplained neutrophilia — MSRA MCQ

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HardMicrohematuriaPersistent non-visible haematuria with albuminuria and unexplained neutrophiliaMSRA

A 63-year-old man is reviewed after non-visible haematuria was detected during assessment of fatigue. He has no visible haematuria, dysuria, urinary frequency, loin pain, fever, weight loss, recent urinary instrumentation or vigorous exercise. He has never smoked and does not have diabetes or hypertension. Three correctly collected midstream urine specimens over 12 weeks show blood 2+, negative and blood 1+ on reagent-strip testing. Nitrites and leucocytes are negative and all urine cultures show no significant growth. Early-morning urine ACR is 41 mg/mmol and 38 mg/mmol on samples taken 13 weeks apart. His eGFR is stable at 84 mL/min/1.73 m², blood pressure is 128/74 mmHg and potassium is normal. Full blood count shows neutrophilia with a white cell count of 12.8 × 10⁹/L, confirmed at 12.5 × 10⁹/L 3 weeks later. He remains systemically well and no infective or inflammatory focus is found. What is the most appropriate next management plan?

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Correct answer: A — Refer using a suspected cancer pathway for bladder cancer and refer for nephrology assessment

This patient needs both referrals. He has persistent invisible haematuria because 2 of 3 appropriately collected reagent-strip samples are positive. At age 63, unexplained non-visible haematuria with a raised white cell count meets NICE NG12 criteria for suspected cancer pathway referral for bladder cancer. The negative cultures and absence of an alternative inflammatory or infective focus support the description of the haematuria and leukocytosis as unexplained. He also meets NICE CKD referral criteria: ACR is persistently above 30 mg/mmol on early-morning samples separated by more than 3 months, and this is accompanied by haematuria. Stable eGFR does not remove this indication for nephrology assessment. A renal ultrasound is appropriate in persistent invisible haematuria with CKD, but it does not substitute for either indicated specialist referral. Optimising renin–angiotensin system blockade alone is not the immediate decisive action and would not address the cancer-pathway criterion. Nephrology referral alone misses the bladder-cancer referral threshold. Conversely, cancer referral alone fails to act on A3 albuminuria with haematuria, for which NICE recommends nephrology assessment.

Reference: NICE NG12: Suspected cancer: recognition and referral — Bladder cancer, recommendation 1.6.4 (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer NICE NG203: Chronic kidney disease: assessment and management — Haematuria and referral criteria (2021; current NICE recommendations checked August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Indications for renal ultrasound (2021; current NICE recommendations checked August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations