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Minimal-Change Disease Workup

  • Author: Abeera Mansur, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
 
Updated: Jan 26, 2015
 

Approach Considerations

Urinalysis findings are benign in minimal-change disease (MCD), but profound proteinuria and oval fat bodies may be observed. In children, the critical level for diagnosis is proteinuria of 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 should be 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.

Other laboratory findings are as follows:

  • Renal function usually is normal except in cases of undiagnosed focal segmental glomerulosclerosis (FSGS) or in those cases that progress to acute renal failure
  • Serologic workup (including antinuclear antibodies, complements, and cryoglobulins) is normal
  • Hyponatremia is often observed and is in part a spurious finding secondary to the hyperlipidemic state; it also occurs from water retention caused by hypovolemia and antidiuretic hormone release
  • Elevated hemoglobin and hematocrit are consequences of plasma volume contraction

Renal sonogram results are normal in patients with MCD.

Because MCD accounts for 90% of all cases of idiopathic nephrotic syndrome in children, renal biopsy is not part of the initial workup for MCD in that age group. Instead, biopsy is performed only in those children who fail to achieve remission with an empiric course of corticosteroids. In contrast, a renal biopsy is performed in all adult patients with nephrotic syndrome, before the initiation of treatment for MCD.

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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.

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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, American Society of Nephrology

Disclosure: Nothing to disclose.

Coauthor(s)

Susie Lew, MD Professor of Medicine, Department of Medicine, Division of Renal Diseases and Hypertension, George Washington Unversity School of Medicine and Health Sciences; Medical Director, Peritoneal Dialysis Unit, George Washington University Medical Center, Gambro Healthcare/DaVita

Susie Lew, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation

Disclosure: Received grant/research funds from Amgen for investigator; Received consulting fee from Gambro for consulting; Received grant/research funds from Questcor for investigator; Received grant/research funds from Bristol Meyers Squibb for investigator; Received grant/research funds from CMS for investigator.

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, American Society of Nephrology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, International Society of Nephrology, American Society for Biochemistry and Molecular Biology, American Federation for Medical Research, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, Kentucky Medical Association, National Kidney Foundation, Phi Beta Kappa

Disclosure: Received grant/research funds from Dept of Veterans Affairs for research; Received salary from American Society of Nephrology for asn council position; Received salary from University of Louisville for employment; Received salary from University of Louisville Physicians for employment; Received contract payment from American Physician Institute for Advanced Professional Studies, LLC for independent contractor; Received contract payment from Healthcare Quality Strategies, Inc for independent cont.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, 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, International Society of Nephrology

Disclosure: Nothing to disclose.

Additional Contributors

Anil Kumar Mandal, MD Clinical Professor, Department of Internal Medicine, Division of Nephrology, University of Florida College 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, Central Society for Clinical and Translational Research

Disclosure: Nothing to disclose.

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