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Minimal Change Disease

by Carlo Raj, MD
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    00:01 Our first nephrotic syndrome, we'll take a look at is the most common type in children.

    00:07 Welcome to minimal change disease.

    00:10 Why do we call this minimal? Because, well, there are three patterns of imaging or staining with biopsy.

    00:18 Those included light microscopy, electron microscopy and immunofluorescence.

    00:23 Now, can you predict us to what you're going to find and a little bit of each one? Let's do it. Ready.

    00:30 Light microscopy. Looks perfectly normal, hence minimal.

    00:35 So when you say minimal change disease, it's the fact that you find minimal changes in light microscopy.

    00:42 Not enough to confirm biopsy, or not enough to confirm diagnosis.

    00:47 Your next pattern biopsy here with electron microscopy, well, a lot more diagnostic because you can find the fusion of foot processes.

    00:56 And then what about immunofluorescence, what can you predict? With immunofluorescence here, would not show any immunoglobulins because that is not the type of pathogenesis that we're seeing.

    01:06 Now, that your child most common.

    01:09 Do not forget that adults may get this as well.

    01:13 It's more common in girls than boys.

    01:14 Now, occurs in 15% of adults with nephrotic syndrome, 15%, what kind of association? It's usually cancer. You should dealing with Hodgkin lymphoma.

    01:27 Keep that in mind.

    01:28 T-cells is where we are here with cytokines.

    01:32 Remember first nephritis, an inflammation, then you're bringing in neutrophils as being your primary pathogenesis.

    01:38 If it's nephrotic syndrome it has to be cytokines mediated by T-cell.

    01:43 Here with T-cell cytokines, you'll have damage to the glomerular basement membrane, gone as a negative charge.

    01:50 Therefore, facilitating the release of your albumin.

    01:53 Albumin, it's selective proteinuria not globulins.

    01:58 Remember, when we did our discussion of urine analysis with the salicylic acid, SSA and that was more specific for looking for globulins, salicylic acid.

    02:10 Here with albumin, it's the fact that you're looking for this through your albumin dipstick.

    02:15 You already know there's lots protein because there'll be generalized edema in your patient.

    02:21 Secondary cause, Hodgkin’s lymphoma.

    02:25 What must you find upon histology with Hodgkin, a Reed-Sternberg cell.

    02:32 What's the most common? Nodular sclerosing.

    02:36 Remember, 15% of your adult may present with minimal change disease, it is the most common in a child.

    02:42 So the mother brings in the child or maybe you're taking your clinical exam and you walk into a room and instead of a patient, there is a telephone. “What?” Don’t panic.

    02:54 You know enough in which you can communicate properly and effectively with the mother on the phone.

    02:59 Now, this real life exam questions and exam scenarios, of course they are.

    03:04 So you get on the phone and the mother tells you that, well, the child is gaining quite a bit of weight, and the child is urinating quite a bit.

    03:10 And now at this point with that type of history, you're already thinking and suspecting that this child probably has minimal change disease.

    03:18 What's your next step in management? Not biopsy. Clear? Not biopsy.

    03:25 So what is your next step in management? Corticosteroids.

    03:28 Is the child going to recover? Yeah, absolutely.

    03:32 Is that make you feel good? Wooh! Yeah! Structural abnormality with minimal change disease stains, you're looking for fat stains.

    03:41 Negative immunofluorescence, we already discussed this. Why? There's nothing to do with immunoglobulins.

    03:47 It's selective for albuminuria.

    03:49 Next, often preceded by respiratory infection or routine immunization.

    03:55 Usually normotensive, so hypertension is usually not present.

    03:59 Then nephrotic syndrome include while we talk about hypoalbuminemia.

    04:02 It's going to be generalized edema and the fact that there is going to be lipoid.

    04:07 Children, will respond quite well to steroid therapy.

    04:13 Try not to do a biopsy in a child.

    04:15 You don’t have as many differentials with these types of symptoms.

    04:19 And so therefore, steroid is your next step in management. Is that clear? Now, if it's an adult, it's different.

    04:25 With an adult, we have a lot more differentials and so therefore your next step in management would be biopsy.

    04:32 Chronic renal failure, thank goodness is rare.

    04:36 When we change this is on electron microscopy, what you are going to find? What would you find on this picture, electron microscopy is the fact that, well, that's with the same thing over and over again, so you get on a habit of looking at this organization pattern.

    04:55 First thing basement membrane, smooth paved road, number one.

    05:01 Number two, what are you looking for? You are looking for feet that put you on the side of your podocyte and epithelial cell.

    05:09 But the problem is this. “Oh my goodness! Where are my feet? I can’t find any feet, Dr. Raj!” You are right, because it all fused.

    05:18 The fusion of the foot process is my problem when dealing with nephrotic syndrome, and the picture is here with MCD that you have fusion of foot process.

    05:29 Clinical features responsive to corticosteroids and the majority will in fact have complete recovery.

    05:36 Fusion foot processes what you're seeing and on a cartoon, if you take a look at where it says epithelium with effaced foot processes.

    05:49 Not a single foot processes seeing on the top of that basement membrane.

    05:53 You see that gray visceral epithelial cell? Beautiful picture there of where you find no foot processes.

    06:01 Would you find any immuno-complexes here? No, you would not.

    06:04 It has nothing to do with immunoglobulin.

    06:07 Findings are current all glomerular disease that present with nephrotic syndrome.


    About the Lecture

    The lecture Minimal Change Disease by Carlo Raj, MD is from the course Glomerulonephritis.


    Included Quiz Questions

    1. Reed Sternberg cells
    2. Hypergammaglobulinemia
    3. Spontaneous peritonitis
    4. Bleeding diathesis
    5. Hypereosinophilia
    1. T-cell cytokines
    2. Neutrophils
    3. C3
    4. IgM
    5. IgA
    1. Clear vacuoles in tubules with H&E stain.
    2. Normal appearance with electron microscopy.
    3. Linear pattern on immunofluorescence.
    4. Granular pattern on immunofluorescence.
    5. Fusion of podocytes on light microscopy.
    1. Bleeding diathesis
    2. Hypercholesterolemia
    3. Polyuria
    4. Spontaneous peritonitis
    5. Weight gain

    Author of lecture Minimal Change Disease

     Carlo Raj, MD

    Carlo Raj, MD


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