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Persistent invisible haematuria with A3 albuminuria — MSRA MCQ

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HardMicrohematuriaPersistent invisible haematuria with A3 albuminuriaMSRA

A 59-year-old woman has had dysuria for 5 weeks. She has no visible haematuria, fever, loin pain, vaginal bleeding, urethral discharge, weight loss, recent urinary instrumentation or vigorous exercise. Samples were collected outside menstruation. Urine cultures on three occasions show no significant growth. Three correctly collected midstream urine specimens over 8 weeks show blood 2+, negative and blood 1+ on reagent-strip testing. Early-morning urine ACR is 38 mg/mmol and 42 mg/mmol on samples taken 13 weeks apart. Her eGFR is stable at 98 mL/min/1.73 m², blood pressure is 124/76 mmHg, and full blood count is normal. She does not have diabetes, hypertension or a family history of kidney disease. 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 — Refer for nephrology assessment for A3 albuminuria with haematuria

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

D is correct. She has persistent invisible haematuria because 2 of 3 reagent-strip tests are positive at 1+ or greater; urine microscopy is not required to confirm this. Her ACR is persistently above 30 mg/mmol on samples more than 3 months apart, placing her in A3 albuminuria despite preserved eGFR. NICE recommends specialist renal assessment for ACR above 30 mg/mmol when accompanied by haematuria. A is attractive because she has unexplained non-visible haematuria and dysuria with sterile cultures. However, the NICE suspected-cancer-pathway threshold for bladder cancer requires age 60 years or over with non-visible haematuria plus dysuria or raised white-cell count. At age 59, she does not meet this criterion. This does not remove the need for appropriate symptom review and safety-netting, but it is not the specified urgent cancer-pathway indication. B is incorrect because NICE advises against using microscopy to confirm a positive dipstick result. C and E underestimate the significance of the combination of confirmed A3 albuminuria and haematuria; preserved renal function does not negate the renal referral criterion.

Reference: NICE NG203: Chronic kidney disease: assessment and management (2021) — https://www.nice.org.uk/guidance/ng203/chapter/recommendations NICE NG12: Suspected cancer: recognition and referral, bladder cancer recommendation 1.6.4 (15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer