Minimal Change Disease (MCD) is a type of nephrotic syndrome characterized by proteinuria and swelling without significant findings on light microscopy. It is caused by a circulating permeability factor that leads to foot process effacement on electron microscopy. MCD is most common in children and responds well to steroid treatment, though relapses are common. Second line treatments include cyclophosphamide or rituximab if relapses are frequent or the patient is steroid dependent.
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Brief explanation of each *refer harrison textbook for details causes of TIN
Acute interstitial nephritis
Chronic interstitial nephritis
Reflux nephropathy
Papillary necrosis
Sickle-cell nephropathy
Thrombotic Microangiopathies are diverse group of disorders wherein thrombocytopenia, hemolytic anemia and organ dysfunction such as Kidney and brain occur . Major recent advances in this field have occurred which opens up oppurtunities to effectively manage its clinical challenges .
Brief explanation of each *refer harrison textbook for details causes of TIN
Acute interstitial nephritis
Chronic interstitial nephritis
Reflux nephropathy
Papillary necrosis
Sickle-cell nephropathy
Thrombotic Microangiopathies are diverse group of disorders wherein thrombocytopenia, hemolytic anemia and organ dysfunction such as Kidney and brain occur . Major recent advances in this field have occurred which opens up oppurtunities to effectively manage its clinical challenges .
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
3. Epidemiology
First described in 1913 by Munk, who called it lipoid
nephrosis due to lipids in tubular epithelial cells and urine
More common in children
70-90% of nephrotic syndromes in kids <10
50% of nephrotic syndromes in kids 10-18
10-15% of primary nephrotic syndromes in adults; 3rd most
common after FSGS and MN
More common in Asia than in North America/Europe
? Biopsy practices? vs genetic or environmental influence
4. Biopsy-Proven Proteinuria Causes (>3g/day)
FIGURE 31-1 Graph depicting the frequencies of different forms of glomerular disease identified in renal
biopsy specimens from patients with proteinuria of more than 3 g of protein per day evaluated at the
University of North Carolina Nephropathology Laboratory. Some diseases that cause proteinuria are
underrepresented because they are not always evaluated by renal biopsy. For example, in many patients steroid-
responsive proteinuria is given a presumptive diagnosis of minimal change glomerulopathy and patients do not
undergo biopsy, and most patients with diabetes and proteinuria are presumed to have diabetic
glomerulosclerosis and do not undergo biopsy.
5. Pathology: Light Microscopy
FIGURE 31-2 Unremarkable light microscopic appearance of a biopsy specimen from a patient with
minimal change glomerulopathy. Glomerular basement membranes are thin, and there is no glomerular
hypercellularity or mesangial matrix expansion. (Jones’ methenamine silver stain, ×300.)
Brenner and Rector’s The Kidney, 9th Ed. CH. 31—Primary Glomerular Disease
6. Pathology: Foot Process Effacement
FIGURE 31-3 Diagrams depicting the ultrastructural features of a normal glomerular capillary loop
(A) and a capillary loop with features of minimal change glomerulopathy (B). The latter has effacement
of epithelial foot processes (arrow) and microvillous projections of epithelial cytoplasm.
Brenner and Rector’s The Kidney, 9th Ed. CH. 31—Primary Glomerular Disease
7. Pathology: Electron Microscopy
FIGURE 31-4 Electron micrograph of a glomerular capillary wall from a patient with minimal
change glomerulopathy showing extensive foot process effacement (arrows) and microvillous
transformation. (×5000.)
Brenner and Rector’s The Kidney, 9th Ed. CH. 31—Primary Glomerular Disease
8. Pathogenesis—T Cell Dysfunction?
Likely the result of abnormal regulation of a T-cell subset and
pathologic elaboration of one or more circulating “permeability
factors”
Circulating factor thought to directly effect the glomerular
capillary wall foot process effacement and fusion
Steroids and alkylating drugs (cyclophosphamide) most effective for
remission
Association with Hodgkins; occurs more frequently than in general pop
Remission tends to occur during viral illnesses like measles known to modify
cell-mediated immunity
Transplanting a kidney from a patient with refractory minimal change
disease rapid disappearance of proteinuria
9. Pathogenesis—B Cells?
Initially thought to be uninvolved or negligible
Recent publications demonstrating response to rituximab
(B20 monoclonal antibody) suggest B cell involvement in
producing permeability factors in circulation
10. Pathogenesis—Does this “permeability
factor” exist?
T-cell hybridoma from MCD patient proteinuria and foot
process effacement in rats
Isolated rat glomeruli + sera from Hodgkins patient with
MCD increased permeability to albumin, improved when
Hodgkins treated but NOT with steroids
2 MCD kidneys transplanted into 2 recipients (oops)
proteinuria at time of grafting decreased to normal in 6
weeks
11. Pathogenesis—What IS this factor?
Hemopexin
Plasma protein with an active isoform that may cause increased
glomerular permeability
Patients with relapsed disease demonstrate increased levels of
hemopexin proteinase activity
Th2-derived cytokine IL-13
Rats with IL-13 overexpression albuminuria,
hypoalbuminemia, up to 80% foot process fusion on biopsy
Patients with relapsed MCD have increased expression
IL-13 induces CD80 expression in rat podocytes foot
process fusion and proteinuria
12. Overexpression of Interleukin-13 Induces
Minimal-Change–
Like Nephropathy in Rats
Background
MCD may be a T cell dependent disorder that results in glomerular
podocyte dysfunction
Th2 cytokine bias in patients with MCD
MCD associated with atopy and allergy
Relapse MCD with elevated IL-4 and IL-13
Association between MCD and Hodgkins’s disease
IL-13 known to be an autocrine growth factor for the Reed-Sternberg
JASN 18 : 1476-1485,2007
13. Hypothesis
IL-13 may play an important role in the development of
proteinuria in MCNS by exerting a direct effect on podocytes,
acting through the IL-13 receptors on the podocyte cell surface,
initiating certain signaling pathways that eventually lead to changes
in the expression of podocyte-related proteins (nephrin, podocin,
and dystroglycan)
IL-13 transfected rat was used as a model in this study
14. Mean 24-h urine albumin excretion
(mg/24 h)
Controls n=17
IL 13 n =41
15. Comparison of control, IL-13-transfected mouse
at experiment end (day 70)
Parameter Control Rats Group 1 Grp 2: neprhrotic
(n=17) (proteinuric rats), rats n=7
n=34
Serum albumin 42.7 +/- 1.8 40.7 +/- 1.3 25.5 +/- 2.2
Urine albumin 0.36 +/- 0.04 3.19 +/- 0.98 9.69 +/- 4.07
Serum cholesterol 1.72 +/- 0.05 2.68 +/- 0.18 6.88 +/- 1.09
Serum IL-13 7.1 +/- 1.8 241.4 +/- 69.5 708.6 +/- 257.7
Nephrin 0.16 +/- 0.03 0.11 +/- 0.01 0.01 +/- 0.005
Podocin 0.25+/- 0.05 0.17 +/- 0.02 0.01 +/- 0.005
Yellow = p <0.001 vs control Red = p<0.001 vs control and Grp 1
16. Histopathologic features on day 70
at killing
(A) Glomerulus of IL-13–transfected rat
showing no significant histologic changes
(periodic acid-Schiff stain).
(B) Glomerulus of IL-13–transfected rat
showing fusion of podocyte foot processes
(arrows).
(C) Glomerulus of control rat showing
normal individual podocyte foot processes
along the glomerular basement membrane
(GBM; arrows).
17. Control IL-13 infected
nephrin
Immunofluorescence staining of
glomeruli for protein expression
of nephrin, podocin, dystroglycan,
podocin and synaptopodin
dystroglycan
synaptopodin
18. Summary
IL-13-transfected rats
Developed minimal change like GN, as evidence by LM and EM changes
Decrease in the expression of nephrin, podocin, and dystroglycan
associated with increased urinary albumin excretion and podocyte foot
process effacement
suggesting that these proteins are essential in maintaining the filtration barrier, thus
controlling glomerular permeability
decrease was not due to loss of podocytes (glomerular expression of WT-1 and
synaptopodin showed no difference between control and IL-13 transfected rats)
19. Pathogenesis—How does the GBM
factor in?
3 structures separate the capillary lumen from Bowman’s space
Fenestrated endothelium
Glomerular Basement Membrane (GBM)
Epithelium with a slit diaphragm between podocyte foot processes
Endothelium and GBM are strongly anionic—negative charges from
sialic acid and heparin sulfate
Normally (-) charge repulses circulating albumin
Theory is that the circulating permeability factor diminishes the anionic
property of the GBM
Slit diaphragm plays a critical role with visible defects on EM in MCD
patients but pathophysiology not understood
24. Etiology—Neoplastic Associations
Hodgkin Lymphoma (0.4%)
Non-Hodgkin Lymphoma and Leukemia
Cases of MCD associated with solid tumors are rare but have
been reported
MCD diagnosis may precede signs and symptoms of the
malignancy
Proteinuria typically resolves with treatment of the
malignancy
25. Etiology—Infectious Associations
Rare associations with syphyllis, tuberculosis, mycoplasma,
ehrlichiosis, Hep C, echinococcus
MCD has been described in HIV infection but collapsing
FSGS much more commonly seen
26. Etiology—Allergy Associations
History of allergy described in up to 30% of cases
Multiple allergens described (fungi, cat fur, poison ivy,
pollen, bee stings, house dust)
Onset and relapses have been triggered by bee stings and
allergic reactions
Limited evidence for involvement of food allergy but one
small dietary study suggested an association (oligoantigenic
diet???)
27. Etiology—Other Glomerular Diseases
Association with IgA Nephropathy, with mesangial IgA
deposits and mild mesangial proliferation seen in
concurrence with MCD on biopsy
Reports of MCD occurring with the following, but rare:
Systemic Lupus Erythematosus
Type 1 Diabetes
Polycystic Kidney Diseases
28. MCD Presentation
Typically sudden onset, over days to a week or two
Weight gain, edema, “frothy” urine
Proteinuria >3 g daily and sometimes 15-20 g/day
Hypoalbuminemia, often <2 g/dL
Most cases also demonstrate hyperlipidemia
Microscopic hematuria fairly common in adults, found in 20-
25% of children
AKI not an infrequent complication in adults, creatinine
elevation typically 30-40% > baseline
40-50% will have hypertension at the time of diagnosis
29. MCD Diagnosis
Renal biopsy needed prior to treatment in adults; children
can be treated presumptively with steroids
Need to demonstrate ALL of the following on biopsy:
Normal glomerular findings on light microscopy
Absence of complement or Ig deposits on immunflourescence
Characteristic diffuse effacement of epithelial foot processes on
EM
30. MCD vs FSGS
Primary FSGS diagnosis requires biopsy findings of segmental
glomerusclerosis in at least 1 glomerulus in addition to
diffuse foot process effacement
Sclerotic changes appear first at the juxtamedullary
glomeruli, which may not be seen in a biopsy sample
containing only outer cortex or with <8 glomeruli on biopsy
Some cases that respond poorly to steroids and progress to
ESRD are thought to have been missed FSGS rather than
MCD at initial diagnosis
31. Odds & Ends
Diagnosis in the elderly may be challenging as changes of aging
may suggest primary FSGS rather than MCD superimposed on
aging glomerulosclerosis of aging should be focal and global
rather than focal and segmental
Nephrotic syndrome + AKI also should consider collapsing
FSGS (idiopathic or HIV), crescentic GN superimposed on
membranous nephropathy, nephrotic syndrome due to
monoclonal Ig deposition (cast nephropathy)
Renal vein thrombosis may occur as a complication of MCD but is
typically CHRONIC in nature and does not cause renal failure due
to collateral circulation
32. MCD Treatment
Glucocorticoid therapy is treatment of choice initially
Prednisone 1 mg/kg daily (max 80 mg daily)
Complete response and remission defined as reduction of
proteinuria to 300 mg/day
Relapse defined as return to 3.5g/day or more after previous
remission
Frequent relapsers defined as 3 or more relapses per year
Remission occurs in 85-90% with steroids but may take several
months to remit in adults (25% take longer than 3-4 months)
Response to initial steroid therapy most important prognostic
indicator
33. MCD Treatment
Glucocorticoid dependance considered relapse on therapy or patients who must
stay on steroids to maintain remission
Glucocorticoid resistane refers to little to no reduction in proteinuria after 16
weeks of adequate prednisone tehrapy
Remissions as well as relapses usually abrupt, occurring within 1-2 weeks
“all or nothing” response
Partial response = ? Diagnosis ?
Relapses may be triggered by infection or allergy
Most relapses occur within one year of stopping therapy but have been known
to occur up to 25 years later
34. MCD Treatment
Diuretics + salt-free diet also important in treatment due to
severe edema + hypertension typically present
If patient remains hypertensive, ARB or ACEI should be
considered for further treatment
Steroid taper should not be started for minimum of 8 weeks
or 1-2 weeks after complete remission
Very slow taper recommended to prevent relapse
35. Treatment—Glucocorticoids
There is only one randomized control treatment trial in
adults with MCD that compared prednisone with no
therapy (n=31).
- 75 % of prednisone treated patients had remission to
<1g/day of proteinuria within 6 months.
- In the untreated group, 50% were in remission at 18
months and approximately 70% at three years.
There are no randomized control trials comparing
prednisone to other agents for the initial therapy in adults
with MCD.
Black DA et al. BMJ 3:p421, 1970.
36. Second Line Therapy
Reasonable to repeat steroid course in patients who relapse off
of steroids
Relapsing while on steroids or frequent relapsers may need
additional treatment
Alkylating agents such as cyclophosphamide can be used but must
be monitored closely
Antimetabolites (azathioprine, mycophenolate mofetil) are often
helpful
CNIs such as cyclosporine or tacrolimus effective but may cause
renal injury
Direct antiproteinuric effect on the podocyte
Continuous low-dose prednisone often considered but must
discuss long-term side effects
37. Second Line Therapy
Cyclosporine tends to achieve a more rapid remission, but
between 60-90% of patients relapse after discontinuation making
cyclosporine dependence a major issue.
Both cyclophosphamide and cyclosporine reported to induce and
maintain remission in up to 60% of MCD patients, less so in
steroid resistant cases (10%).
No prospective trials on second-line treatment; all have been
retrospective observational reports.
38. Sources
www.uptodate.com
“Etiology, clinical features, and diagnosis of minimal change
disease in adults”
“Treatment of minimal change disease in adults”
Greenburg, A. Primer on Kidney Diseases,5th Edition.
NKF, 2009. Chapter 17, Minimal Change Nephrotic
Syndrome, pp. 160-164.
Brenner and Rector’s The Kidney, 9th Edition. CH. 31,
Primary Glomerular Diseases.
www.slideshare.com
Mean 24-h urine albumin excretion (mg/24 h) of control rats ( n = 17) and IL-13 –transfected rats ( n = 41) measured at 14-d intervals. Data are means ± SEM.
Immunofluorescence examination showed that nephrin, podocin, and dystroglycan all stained strongly as a continuous granular pattern along the GBM in the control rats . This was in contrast to the nephrotic rats, in which the fluorescence signal was much weaker and in a discontinuous, and sometimes segmental, granular pattern along the GBM Of note, there was no significant difference between the control and nephrotic rats in the expression of synaptopodin, which showed strong and continuous staining along the GBM. In FSGS usually podocytopenia results where there’s decrease in the number of podocyte 2/2 stress, injury, intrinsic factor. IN MCD, there’s a phenotypic change with decrease in absolute no of podocyte.
… . , because the glomerular expression of WT-1 and synaptopodin, which are specific cell surface markers of podocytes, showed no significant difference between the control rats and the IL-13 –transfected rats