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Chapter 25: Minimal Change Disease

A 2-year-old boy is brought to his pediatrician’s office because of progressive abdominal and periorbital swelling. He has had only two wet diapers in the past 24 hours, his appetite is less than his baseline, and he has had a runny nose for the past 1 week. He has had no fever or vomiting and remains playful. He has been a healthy boy with no previous illnesses except for otitis media at age 16 months. His pregnancy and delivery were uneventful. There is no family history of cardiac, liver, thromboembolic, or kidney disease.

On physical examination, his temperature is 37.4°C, his blood pressure is 93/47 mm Hg, and his heart rate is 96 beats/min. His examination is normal except for moderate periorbital edema, dullness on percussion of his lung bases, marked abdominal distension, and mild scrotal swelling. His urinalysis shows a pH of 6.0, specific gravity of 1.030, and negative dipstick except for 4+ protein. His H/H is 13.7/48, platelets are 434,000, and his white blood count (WBC) is 9.4 with a normal differential.

What additional testing is indicated at this time?

A. Blood culture, urine culture, and strep testing

B. Kidney biopsy

C. Urine total protein/creatinine ratio, serum cholesterol, C3 complement, antinuclear antibody (ANA), and blood chemistries—electrolytes, blood urea nitrogen (BUN), creatinine, serum albumin

D. Echocardiogram

The answer is C. This child is very likely to have minimal change nephrotic syndrome. He is in the peak age group of presentation, and at his age there is a 2:1 prevalence of boys to girls with MCD. The absence of hematuria makes the likelihood of an inflammatory glomerular lesion such as post infectious glomerulonephritis highly unlikely. However, a C3 and ANA are typically ordered for completeness sake, though the yield is very low. An echocardiogram is not indicated as the anasarca can be explained on the basis of his nephrotic syndrome. Although not necessary, a chest radiograph should confirm the suspicion of pleural effusions. Children presenting with nephrotic syndrome have a greater than 95% chance of having minimal change disease so a kidney biopsy is not necessary before starting empiric therapy with corticosteroids.

A 38-year-old woman comes into your office with complaints of progressive ankle and leg swelling over the past 2–3 weeks. She has gained 15 lb, notices that her eyelids are swollen in the morning, and the waist of her pants is very tight. Her stools have been loose, and she has mild intermittent abdominal pain. Her knee and ankle joints feel tight. She denies any red or brown urine, preceding illness, sore throat, rashes, fever, shortness of breath, or other constitutional symptoms. She ...

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