eMedicine Specialties > Nephrology > Glomerular Diseases

Minimal-Change Disease: Differential Diagnoses & Workup

Author: Abeera Mansur, MD, Consultant Nephrologist, Doctors Hospital and Medical Center, Pakistan
Coauthor(s): Florin Georgescu, MD, Consulting Staff, Kidney Specialists of Savannah; Susie Lew, MD, Professor, Department of Medicine, Division of Renal Diseases and Hypertension and Nephrology, George Washington University Medical Center
Contributor Information and Disclosures

Updated: Oct 15, 2009

Differential Diagnoses

Other Problems to Be Considered

C1q nephropathy
Focal segmental glomerulosclerosis
Immunoglobulin M (IgM) nephropathy
Membranous nephropathy
Other variables

Workup

Laboratory Studies

  • Urine analysis is benign, but profound proteinuria and oval fat bodies may be observed.
    • In children, the critical level for diagnosis is more than 40 mg/h/m2.
    • In adults, the threshold is more than 3.5 g/d/1.73 m2.
  • A random albumin-to-creatinine concentration ratio is in excess of 5.
  • Urine specific gravity is high because of proteinuria.
  • A 24-hour urine measurement is obtained for protein and creatinine clearance.
  • Hypoalbuminemia is an important marker of nephrotic syndrome. The level at which edema occurs varies, but it tends to be lower in children than in adults. Nephrotic syndrome in children is defined by a serum albumin of less than 2.5 g/dL.
  • Hyperlipidemia also is a feature of a nephrotic state.
  • Renal function usually is normal except in cases of undiagnosed FSGS or in those cases that progress to acute renal failure.
  • Serologic workup (including antinuclear antibodies, complements, and cryoglobulins) is normal.
  • Hyponatremia often is observed, which is, in part, a spurious finding secondary to the hyperlipidemic state. This condition also occurs from water retention caused by hypovolemia and antidiuretic hormone release.
  • Elevated hemoglobin and hematocrit are consequences of plasma volume contraction.

Imaging Studies

  • Renal sonogram is normal.

Procedures

  • Because of the high prevalence of MCD in children with nephrotic syndrome, an empiric trial of corticosteroids commonly is the first step in therapy. Renal biopsy typically is performed only in resistant cases. Generally, if proteinuria remains after 2 relapses or courses of steroids, a tissue diagnosis should be made before starting cytotoxic or immunosuppressive therapy.

Histologic Findings

Light microscopy: In patients with MCD, the glomerulus is, by definition, normal or nearly so when examined with the light microscope; however, the precise limits of normal are not clearly defined. This creates difficulty in differentiating the appearance of minimal change with mild mesangial proliferation from a mesangial proliferative glomerulonephritis. Diagnosis can be even more difficult because, at the peak age of onset (approximately 3 y), the mesangial and epithelial cells are more prominent. In adult patients, diagnosis is made more challenging by superimposed arterionephrosclerosis secondary to hypertension. In children with frequently relapsing MCD, some involuted glomeruli may be present. These lesions are small and sclerotic but retain their podocyte and parietal epithelial cell constituents. The presence of these glomeruli is related to the duration of the disease.

The most common tubular lesion is protein and lipid droplets in epithelial cells due to increased reabsorption. The presence of areas of tubular atrophy and interstitial fibrosis should raise the suspicion of FSGS.

Immunohistology: These studies usually do not demonstrate significant glomerular deposition of immunoglobulins or complement components in patients with MCD. Some biopsy specimens may be positive for low-level IgM deposits not accompanied by mesangial dense deposits.

Electron microscopy: Retraction of the epithelial foot processes is observed consistently in patients with MCD. This is, at times, erroneously described as foot-process fusion and results from disordered epithelial cell structure with withdrawal of the dendritic process. This finding is not unique to MCD, and the diagnosis is one of exclusion of other diseases based on lack of other processes on light microscopy, immunohistology, or electron microscopy.

More on Minimal-Change Disease

Overview: Minimal-Change Disease
Differential Diagnoses & Workup: Minimal-Change Disease
Treatment & Medication: Minimal-Change Disease
Follow-up: Minimal-Change Disease
References
Further Reading
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References

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Keywords

minimal-change disease, nephrotic syndrome, focal segmental glomerulosclerosis, idiopathic nephrotic syndrome of childhood, lipoid nephrosis, minimal-change nephropathy, minimal-change nephrotic syndrome, nil disease, steroid-sensitive nephrotic syndrome

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Contributor Information and Disclosures

Author

Abeera Mansur, MD, Consultant Nephrologist, Doctors Hospital and Medical Center, Pakistan
Abeera Mansur, MD is a member of the following medical societies: American College of Physicians and American Society of Nephrology
Disclosure: Nothing to disclose.

Coauthor(s)

Florin Georgescu, MD, Consulting Staff, Kidney Specialists of Savannah
Florin Georgescu, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and American Society of Nephrology
Disclosure: Nothing to disclose.

Susie Lew, MD, Professor, Department of Medicine, Division of Renal Diseases and Hypertension and Nephrology, George Washington University Medical Center
Susie Lew, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology, International Society of Nephrology, and National Kidney Foundation
Disclosure: Amgen Consulting fee Consulting; Amgen Grant/research funds investigator; Amgen Honoraria Speaking and teaching; OrthoBio Honoraria Speaking and teaching; Fresineus Honoraria Speaking and teaching; Affymax Grant/research funds Other

Medical Editor

Anil Kumar Mandal, MD, Clinical Professor, Department of Internal Medicine, Division of Nephrology, University of Florida School of Medicine
Anil Kumar Mandal, MD is a member of the following medical societies: American College of Clinical Pharmacology, American College of Physicians, American Society of Nephrology, and Central Society for Clinical Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eleanor Lederer, MD, Consulting Staff, Louisville VA Hospital; Professor of Medicine; Interim Chief of Nephrology; Director of Nephrology Training Program; Director, Metabolic Stone Clinic; Director of Outpatient Clinics, Kidney Disease Program, University of Louisville School of Medicine
Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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