Minimal Change Disease
On this page
Direct answer
Nil disease, the older textbooks called it: light microscopy shows normal glomeruli, immunofluorescence is blank, and only electron microscopy earns its fee, revealing diffuse podocyte foot-process effacement — the sole structural abnormality in a child with full-blown nephrotic syndrome. Ninety per cent of children remit on prednisolone 2 mg/kg per day within four to six weeks, whereas adults need 1 mg/kg for up to sixteen weeks and develop acute kidney injury far more often. The disease's real exam weight lies in its definitions — frequent relapser, steroid-dependent, steroid-resistant — because those labels, not the histology, drive every drug choice from levamisole to rituximab.
What you must remember
- Epidemiology: the commonest cause of nephrotic syndrome in children — the great majority of cases under ten years, boys affected twice as often; in adults it explains only about a quarter of nephrotic syndrome.
- Doses to quote: children — prednisolone 60 mg/m² or 2 mg/kg daily until remission, then prolonged alternate-day taper; adults — 1 mg/kg for up to sixteen weeks before calling it steroid-resistant.
- Definitions: frequent relapser — two or more relapses within six months or four within twelve; steroid-dependent — relapse on tapering or within two weeks of stopping; steroid-resistant — no remission despite adequate dosing, mandating biopsy to unmask focal segmental glomerulosclerosis.
- Selective proteinuria: albumin leaks preferentially, an old discriminator that still appears in viva questions.
- Secondary causes: NSAIDs, lithium, interferon, and — the favourite — Hodgkin lymphoma, where the nephrotic syndrome can precede the diagnosis by months.
- Levamisole: 2.5 mg/kg on alternate days, a steroid-sparing mainstay for frequently relapsing disease in Indian and UK paediatric practice; watch the white count for agranulocytosis.
- Second-line ladder: cyclophosphamide for eight to twelve weeks (fertility-sparing in girls, gonadal risk cumulative in boys), then calcineurin inhibitors, mycophenolate, and rituximab for steroid- or calcineurin-dependent disease.
- Childhood biopsy exceptions: age under one year, gross haematuria, hypertension, low complement, renal impairment or steroid resistance — otherwise biopsy is withheld in the classic presentation.
A relapse in a six-year-old
A six-year-old boy, third relapse of oedema and 4+ proteinuria in eight months, first diagnosed at four and steroid-responsive each time. Step one: confirm true relapse — spot protein-creatinine ratio above 200 mg/mmol or three days of 3+ dipstick — and exclude the intercurrent upper respiratory infection that triggered it, since treating the trigger shortens the relapse. Step two: reinduce with daily prednisolone 60 mg/m² until the urine is protein-free for three consecutive days, then hold the daily dose four more weeks before stepping to alternate days; this ISKDC-style rhythm is what the viva examiner wants recited. Step three: he is now, by arithmetic, a frequent relapser — so the steroid-sparing conversation begins, and in an Indian paediatric clinic levamisole is usually first: alternate-day dosing for twelve weeks or more, with a monthly white cell count. Step four: if relapses continue on levamisole, move to ciclosporin or tacrolimus with their gingival, cosmetic and nephrotoxic costs, and reserve cyclophosphamide for the child who relapses off everything. Step five: examinable housekeeping — pneumococcal vaccination, varicella status, penicillin prophylaxis during relapse in some units, and a warning card that live vaccines wait until steroids fall below 1 mg/kg on alternate days.
Where students slip
Candidates misapply child logic to adults. An adult with nephrotic syndrome is biopsied before any label — adults are not treated blind, and their remission lag stretches to sixteen weeks, so "steroid-resistant at six weeks" is a paediatric definition only. The second slip is dismissing minimal change as benign: the nephrotic state carries genuine hazards — pneumococcal peritonitis in the child with ascites is a classic Indian exam stem — along with thrombosis and hypovolaemic collapse. The third is forgetting the paraneoplastic thread: new nephrotic syndrome in a middle-aged adult with weight loss and lymphadenopathy is Hodgkin lymphoma until the biopsy and the CT say otherwise, and the nephrotic syndrome often remits when the lymphoma does.
Frequently asked questions
What dose of prednisolone induces remission in a child?
2 mg/kg or 60 mg/m² daily until the urine is protein-free for three days, followed by four weeks of daily dosing and a slow alternate-day taper.
What defines steroid-resistant disease?
Failure to achieve remission after an adequate steroid course — four to six weeks in children, sixteen weeks in adults — which mandates biopsy to exclude focal segmental glomerulosclerosis.
Which children are biopsied before any steroid?
Those under one year, or with gross haematuria, hypertension, low complement, renal impairment, or steroid resistance — the classic exception list.
What is levamisole's role?
Alternate-day steroid-sparing therapy for frequently relapsing disease, popular in Indian paediatric practice, with monitoring for neutropenia.
Why does acute kidney injury complicate adult minimal change more than childhood disease?
Older kidneys with arteriosclerosis tolerate the hypovolaemia and tubular changes of severe nephrotic syndrome poorly, producing prerenal and ischaemic injury.
Which malignancy associates with minimal change disease?
Hodgkin lymphoma — the nephrotic syndrome may be its presenting feature and remits with successful oncological treatment.