Minimal change disease caused by exposure to mercury-containing skin lightening cream: a report of 4 cases

Mercury is a known cause of nephrotic syndrome and the underlying renal pathology in most of the reported cases was membranous nephropathy. We describe here 4 cases of minimal change disease following exposure to mercury-containing skin lightening cream for 2 - 6 months. The mercury content of the facial creams was very high (7,420 - 30,000 parts per million). All patients were female and presented with nephrotic syndrome and heavy proteinuria (8.35 - 20.69 g/d). The blood and urine mercury levels were 26 - 129 nmol/l and 316 - 2,521 nmol/d, respectively. Renal biopsy revealed minimal change disease (MCD) in all patients. The use of cosmetic cream was stopped and chelation therapy with D-penicillamine was given. Two patients were also given steroids. The time for blood mercury level to normalize was 1 - 7 months, whereas it took longer for urine mercury level to normalize (9 - 16 months). All patients had complete remission of proteinuria and the time to normalization of proteinuria was 1 - 9 months. Mercury-containing skin lightening cream is hazardous because skin absorption of mercury can cause minimal change disease. The public should be warned of the danger of using such products. In patients presenting with nephrotic syndrome, a detailed history should be taken, including the use of skin lightening cream. With regard to renal pathology, apart from membranous nephropathy, minimal change disease should be included as another pathological entity caused by mercury exposure or intoxication.

[Family occurrence of steroid-sensitive idiopathic nephrotic syndrome]

Nephrotic syndrome (NS) presented within three weeks in siblings aged six and ten years. Both children experienced proteinuria, hypoalbuminaemia and oedema, with the most pronounced symptoms in the older. Standard treatment with prednisolone led to remission of the nephrotic syndrome in the younger, whereas the older required additional therapy with tacrolismus before remission. In view of the low incidence of NS in children, a near simultaneously onset in two siblings must lead to genetic elucidation. Genetic disorders and other causes of childhood NS are discussed.

Proteinuria predicts relapse in adolescent and adult minimal change disease

OBJECTIVE

This study sought to outline the clinical and laboratory characteristics of minimal change disease in adolescents and adults and establish the clinical and laboratory characteristics of relapsing and non-relapsing patients.

METHODS

We retrospectively evaluated patients with confirmed diagnoses of minimal change disease by renal biopsy from 1979 to 2009; the patients were aged >13 years and had minimum 1-year follow-ups.

RESULTS

Sixty-three patients with a median age (at diagnosis) of 34 (23-49) years were studied, including 23 males and 40 females. At diagnosis, eight (12.7%) patients presented with microscopic hematuria, 17 (27%) with hypertension and 17 (27%) with acute kidney injury. After the initial treatment, 55 (87.3%) patients showed complete remission, six (9.5%) showed partial remission and two (3.1%) were nonresponders. Disease relapse was observed in 34 (54%) patients who were initial responders (n = 61). In a comparison between the relapsing patients (n = 34) and the non-relapsing patients (n = 27), only proteinuria at diagnosis showed any significant difference (8.8 (7.1-12.0) vs. 6.0 (3.6-7.3) g/day, respectively, p = 0.001). Proteinuria greater than 7 g/day at the initial screening was associated with relapsing disease.

CONCLUSIONS

In conclusion, minimal change disease in adults may sometimes present concurrently with hematuria, hypertension, and acute kidney injury. The relapsing pattern in our patients was associated with basal proteinuria over 7 g/day.

The many faces of minimal change nephrotic syndrome: an overview and case study

Idiopathic nephrotic syndrome is the most common form of nephrotic syndrome in the pediatric population. Three major histopathological findings have been identified. The most common is that of minimal change nephrotic syndrome. Most of these cases respond well to oral steroids and achieve long-term remission. For those that become steroid dependent, the clinical course can be quite difficult. The case study included demonstrates some of the difficulties that can be encountered and questions that still exist with management of this diagnosis.

[Correlation between Chinese medicine syndromes and the NPHS1 gene and NPHS2 gene polymorphism as well as corticosteroid sensitivity in patients with minimal change disease]

OBJECTIVE

To explore the correlation between Chinese medicine (CM) syndromes and the NPHS1 gene and NPHS2 gene polymorphism as well as corticosteroid sensitivity in patients with minimal change disease (MCD).

METHODS

A total of 94 MCD patients were recruited, including 58 steroid-sensitive nephritic syndrome (SSNS) patients and 36 steroid-resistant nephritic syndrome (SRNS) patients. Genomic DNA was obtained from peripheral blood lymphocytes and sequence analysis of single nucleotide polymorphisms (SNPs) in the genes was performed.

RESULTS

(1) The SNPs of G349A-3 in NPHS1 gene was found in MCD, but the SNPs of G686A-5 and C695T-5 in NPHS2 gene were not discovered in MCD. (2) When comparing the frequency of genotype AA and allele A in NPHS1 gene (G349A-3), genotype AA and allele A were higher in the SRNS group than in the SSNS group (P < 0.05). (3) When compared with the SRNS group, qi yang deficiency syndrome had a higher incidence in the SSNS group, and yin deficiency syndrome and qi-yin deficiency syndrome had a less incidence in the SSNS, but with no statistical difference (P > 0.05). The rheumatism syndrome had a higher incidence in the SSNS group (P < 0.05). The blood stasis syndrome had a lower incidence in the SSNS with statistical difference (P < 0.05). (4) There was no statistical difference in the correlation between GG, AA, GA and CM syndromes (P > 0.05).

CONCLUSIONS

Homozygous mutations of AA and allele A in NPHS1 gene were correlated to SRNS patients of MCD. Rheumatism syndrome patients were prone to be sensitive to corticosteroids, while patients of blood stasis syndrome were prone to be insensitive to corticosteroids. We didn't discover the correlation between NPHS1 gene polymorphism and CM syndrome distribution.

Procalcitonin and minimal-change nephropathy: a pilot study

INTRODUCTION

This study assessed the role of procalcitonin (PCT) in the differentiation of minimal-change nephropathy (MCN) relapses from infections co-existent with proteinuria flares in children.

METHODS

Data on the PCT levels of patients with MCN who were on follow-up were retrospectively gathered at relapse (Group I), during proteinuria attacks co-existent with intercurrent infection (Group II) and at remission (Group III). The results of these three groups were then prospectively compared with nephrologically healthy patients who had infections that were similar to those in Group II (Group IV), and controls (Group V).

RESULTS

Significant differences in PCT level were noted between patients of Groups I, II and IV and the other two groups. A 93% reduction in proteinuria was achieved for Group II patients following an antibiotic regimen. The difference in PCT level between Groups I and II was significant. PCT showed a higher diagnostic predictability than C-reactive protein (CRP) in Group I patients, and was as good as CRP for those with infection and infection-related proteinuria. Sensitivity × specificity in relapse and infection-related states for PCT were 0.472 and 0.628, respectively, and those for CRP were 0.183 and 0.762, respectively.

CONCLUSION

A combined approach with CRP and PCT readings may be beneficial in discriminating proteinuria attacks co-existent with intercurrent infection from sole relapses of nephrotic syndrome. PCT may be a part of the wide spectrum of immune abnormalities seen in patients with MCN.

Percutaneous renal biopsy results: a retrospective analysis of 511 consecutive cases

To determine the patterns of the prevalent glomerulonephritis (GN) in our region, we studied the results of 511 consecutive renal biopsies performed on patients with proteinuria, hematuria and mild to moderate renal impairment at the Aga Khan University Hospital during a period of 18 years from January 1990 to December 2008. Primary glomerular disease accounted for two-thirds of the glomerular diseases, which in turn constituted 49% of all renal biopsies. The most common histological lesion was membranoproliferative disease (28%). Membranous GN was the second most common lesion (19%), followed by minimal change disease (16%) and focal segmental GN (11%). Secondary glomerular disease comprised 30% of glomerular diseases (21% of all the renal biopsies), with lupus nephritis forming the most common lesion (34%) followed by amyloidosis (22%), diabetic nephropathy (10%), Wagener's granulomatosus and post-infectious GN (9% each). Tubulointerstitial diseases accounted for 16% of all the renal biopsies. We conclude that there exists a wide variability in the different categories of primary and secondary glomerular diseases in our region as compared with different parts of the world. Future studies should be directed to analyze the causes for these variations.

Reversible minimal change nephrotic syndrome and glomerular IgA deposition associated with nonparenteral heroin abuse: a case report

OBJECTIVE

To report for the first time a case of reversible minimal change nephrotic syndrome with immunoglobulin A (IgA) deposition associated with heroin.

CLINICAL PRESENTATION AND INTERVENTION

A 29-year-old male heroin abuser who developed nephrotic syndrome was admitted to our clinic. Renal biopsy revealed minimal change disease with IgA deposition. Because spontaneous complete remission was observed after cessation of heroin, a diagnosis of minimal change nephrotic syndrome with IgA deposition associated with heroin abuse was considered.

CONCLUSION

This case showed minimal change nephrotic syndrome with IgA deposition that had a benign clinical course.

[Clinical characteristics of adult-onset minimal change nephrotic syndrome in our hospital]

OBJECTIVE

Few findings are available regarding adult-onset minimal change nephrotic syndrome (MCNS) with respect to the disease course and complications, such as acute kidney injury (AKI). We therefore performed a retrospective review to characterize the clinical presentations, steroid responsiveness and complications of adult-onset MCNS patients in our hospital.

PATIENTS AND METHODS

We retrospectively reviewed 40 cases of idiopathic adult-onset MCNS who had been investigated and treated at a single center. Patients between 18 and 50 years of age (Younger group) at the time of biopsy were compared with those older than 50 years (Older group) with regard to demographic data, clinical features and treatment outcome.

RESULTS

Baseline characteristics of the 40 patients were: median age, 42 years (interquartile range: 28-63 years); male, 70%; mean (+/- standard deviation) systolic and diastolic blood pressures, 125 +/- 17 mmHg and 78 +/- 12 mmHg, respectively; estimated glomerular filtration rate (eGFR), 74 mL/min/1.73 m2 (range: 64-94 mL/min/1.73 m2); serum albumin, 1.8 +/- 0.3 g/dL; and urinary protein, 7.8 g/day (range: 3.9-10.4 g/day). All except for one patient received steroid pulse therapy. Time to complete response (CR) was 12 days (range: 8-21 days). Time to CR was significantly longer in the Older group (p = 0.011). The Late-responder group (time to CR > 2 weeks)was significantly older (p < 0.01), with a low eGFR (p < 0.001) and a higher prevalence of interstitial fibrosis in renal biopsy before the initiation of corticosteroid therapy (p < 0.05), compared with the Early-responder group. AKI was observed in 14 patients. Patients with an episode of AKI were significantly older (p = 0.005), with a lower eGFR (p < 0.002) and a higher prevalence of cellular casts (p < 0.05). At the follow-up, 19 patients (51%) had experienced relapses. The relapse rate was significantly lower in the Older group than in the Younger group (p < 0.05).

CONCLUSION

The present study revealed that older patients had a longer period to CR and a higher risk of AKI at follow-up.

Spontaneous remission of immunotactoid glomerulopathy

Immunotactoid glomerulopathy (ITG ) is a rare cause of nephrotic syndrome, occurring in approximately 0.1% of native kidney biopsies. We describe a 43-year-old woman who presented with a nephrotic syndrome. Renal biopsy revealed a membranous pattern of glomerular injury. In electron microscopy the subepithelial deposits were comprised of 40 nm wide tubular structures, confirming ITG . During follow-up the patient developed a remission of proteinuria with only supportive treatment.

Minimal-change nephrotic syndrome associated with isoniazid in anti-tuberculosis chemoprophylaxis for a patient with rheumatoid arthritis

A 66-year-old woman with seropositive rheumatoid arthritis (RA) and latent tuberculosis infection developed minimal-change nephrotic syndrome following the initiation of anti-tuberculosis chemoprophylaxis with isoniazid. This is the first reported case of an isoniazid-induced nephrotic syndrome. Isoniazid as a single-drug intervention is widely accepted as a safe and effective means of anti-tuberculosis chemoprophylaxis, particularly for RA patients with latent tuberculosis infection; the present case, however, demonstrates that isoniazid has the potential to induce minimal-change nephrotic syndrome, even when used as a single-drug intervention.

Glomerular malondialdehyde levels in patients with focal and segmental glomerulosclerosis and minimal change disease

Minimal change disease (MCD) and focal and segmental glomerulosclerosis (FSGS) are often studied together, because both present with heavy proteinuria and the nephrotic syndrome. The precise distinction between MCD and FSGS is sometimes difficult because of inadequate number of glomeruli for definite diagnosis. Some evidence suggests that markers of lipid peroxidation, such as malondialdehyde (MDA) is an index of free radical mediated injury and may be involved in the pathogenesis of FSGS. In this study, we assessed the immunoreactivity of MDA, the end product of lipid peroxidation in glomeruli of patients with idiopathic FSGS, MCD as well as normal controls (NC). Our results showed that the immunostaining level of MDA was significantly higher in patients with FSGS (mean = 1.5) than in either patients with MCD (mean = 0.16) or normal controls (mean = 0.11) with P value < 0.001. Glomerular MDA level correlated well with the degree of glomerulosclerosis in patients with idiopathic FSGS. Our data demonstrates that the glomerular level of MDA is higher in idiopathic FSGS than MCD. We suggest that MDA immunostaining can be helpful in differentiating between FSGS and MCD in problematic cases and when we do not have enough glomeruli for definite and correct diagnosis.

Urinary excretion of IGFBP-1 and -3 correlates with disease activity and differentiates focal segmental glomerulosclerosis and minimal change disease

The glomerular microenvironment is influenced by circulating growth factors that are filtered from the blood stream and pass the glomerular filtration barrier. In this study, we wanted to explore the role of IGF-binding proteins (IGFBPs) in two diseases that concern podocytes. We analyzed glomerular expression and urinary excretion of IGFBP-1, -2, and -3 in patients with focal segmental glomerulosclerosis (FSGS) or minimal change disease (MCD). We found that patients with active FSGS excrete high amounts of podocalyxin positive cells as well as IGFBP-1 and -3. In human podocytes, we can induce mRNA expression of IGFBP-3 in response to TGF-beta and in human microvascular endothelial cells expression of IGFBP-1 and -3 in response to TGF-beta and Bradykinin. We conclude that the local expression of IGFBPs in podocytes and endothelial cells might contribute to the pathogenesis of glomerular disease and that IGFBP-1 and -3 are potential non-invasive markers of FSGS.

A rare cause of nephrotic syndrome: lipoprotein glomerulopathy

Lipoprotein glomerulopathy is a rare kidney disease in which lipoprotein thrombi are seen in the glomerular capillaries. Most of these patients are found in Japan and East Asian countries. The presenting symptoms include proteinuria, an abnormal plasma lipoprotein profile that resembles type III hyperlipoproteinaemia, and a marked increase in serum apolipoprotein E concentration. Previous studies have suggested that lipoprotein glomerulopathy might be related to APOE gene mutation. No effective therapeutic regimen has been established for lipoprotein glomerulopathy. We report the first case of biopsy-proven lipoprotein glomerulopathy in Hong Kong in a patient who presented with nephrotic syndrome and dyslipidaemia. DNA analysis revealed apolipoprotein E Kyoto together with a novel apolipoprotein E mutation, apolipoprotein E (Asp230Tyr) Hong Kong. There was significant improvement in the clinical parameters and resolution of symptoms after the introduction of statins. Further studies will be needed to clarify the role of apolipoprotein E Hong Kong and its interaction with apolipoprotein E Kyoto in the pathogenesis of lipoprotein glomerulopathy.

Minimal change disease versus IgA nephropathy

IgA nephropathy is the most common type of the glomerulonephritis all over the world. However, its clinical presentation is variable, as is the underlying histopathological lesion. We report herein a case of an adult with steroid responsive minimal change disease and IgA mesangial deposits. During the first two weeks of therapy with prednisolone, the patient reported dramatic improvement in his clinical condition and remitted his disease. Unfortunately, at the end of the second month of prednisolone therapy, an acute flare of viral hepatitis was diagnosed. Interes-tingly, the acute viral flare was without a concomitant relapse of proteinuria.

[Case of goodpasture syndrome associated with minimal change nephrotic syndrome (MCNS) in a patient with rheumatoid arthritis (RA)]

In early June 2004, a 50-year-old female was admitted to the hospital for slight fever, general fatigue, hemoptysis, dyspnea, and renal dysfunction (serum creatinine[Cr] : 6.05 mg/dL). She had been treated with prednisolone (PSL : 10-20 mg/day) for RA. She was diagnosed with Goodpasture syndrome based on a high titer of anti-glomerular basement membrane antibody (87 EU), and pulmonary hemorrhage. The renal and pulmonary impairments were markedly improved by the pulse therapy, plasma exchange and temporary hemodialysis. However, the Cr level remained at 2.0 mg/dL, indicating nephrotic syndrome. Light microscopy with Periodic acid-Shiff(PAS) staining demonstrated global sclerosis in three of ten glomeruli. Five glomeruli showed the formation of cellular, and fibrocellular crescents, and the formation of fibrous crescents. Tubular damage and interstitial fibrosis were severe. Immunofluorescence microscopy disclosed major depositions of IgG in a linear pattern along the glomerular basement membrane(GBM). Electron microscopy revealed foot process effacement (>50%)and no electron-dense deposits. Therefore, we diagnosed Goodpasture syndrome associated with minimal change nephrotic syndrome (MCNS). Some reports have dealt with the association of RA and Goodpasture syndrome with D-penicillamine, and of RA and antineutrophil cytoplasmic antibodies (ANCA)-related vasculitis with pulmonary hemorrhage, but none has dealt with cases complicated with RA and Goodpasture syndrome associated with MCNS. Accordingly, whether or not there is a causal relationship between RA and Goodpasture syndrome remains obscure, but since the number of reported cases is small, experience with more cases is necessary to clarify this matter.

Immunohistochemical detection of galectin-1 in renal biopsy specimens of children and its possible role in proteinuric glomerulopathies

AIMS

Galectin-1 is an endogenous lectin that specifically binds to beta-galactoside structures. It has been associated with developmental mechanisms ranging from differentiation to apoptosis and exerts immunoregulatory functions in autoimmune diseases. The aim was to determine the immunohistochemical expression of galectin-1 in renal biopsy specimens of children with primary idiopathic proteinuric glomerulopathies.

METHODS AND RESULTS

We examined 18 children with minimal change disease (MCD), 30 with diffuse mesangial proliferation (DMP) and 11 with focal segmental glomerulosclerosis (FSGS). An indirect immunohistochemical protocol using a polyclonal antibody directed against galectin-1 was applied. Galectin-1 was detected in renal podocytes in DMP and FSGS cases, while control glomeruli and MCD were negative. Galectin-1 immunoreactivity was found within parietal epithelial cells in patients with FSGS.

CONCLUSIONS

These results suggest a possible role for galectin-1 in the pathogenesis of primary glomerulopathies in children as a kind of podocyte-related self-protective activity and probably involvement of epithelial cells of Bowman's capsule in inflammatory processes. Immunohistochemistry using galectin-1 antibodies may further be helpful in histological distinction between MCD and DMP.

Tacrolimus as a steroid-sparing agent for adults with steroid-dependent minimal change nephrotic syndrome

BACKGROUND

Treatment of adults with steroid-dependent minimal change nephrotic syndrome (SD-MCNS) can be a significant challenge. Cyclophosphamide (CYC) and cyclosporin (CYA) are often effective steroid-sparing agents. Tacrolimus (TAC) may be another treatment option.

METHODS

This open, prospective cohort study enrolled Chinese adults with SD-MCNS. At the start of the study, we administered TAC or intravenous CYC together with prednisone (0.5 mg/kg/day), the dose of which was tapered off throughout the study. The TAC cohort received oral TAC (target trough blood level of 4-8 ng/ml) for 24 weeks and the CYC cohort received intravenous CYC (750 mg/m(2) body surface) once every 4 weeks for 24 weeks.

RESULTS

Twenty-six patients met the criteria for enrollment (14 patients in the CYC group and 12 patients in the TAC group). One patient from each group discontinued treatment because of a drug-related side effect. Complete remission (CR) after the 24-week therapeutic period was 76.9% (10/13) in the CYC group and 90.9% (10/11) in the TAC group. The mean time required for CR in the TAC group was significantly less than in the CYC group (P = 0.031). Eight of 13 (61.5%) patients in the CYC group and 8 of 11 (72.7%) patients in the TAC group successfully stopped steroids and changed their status from steroid dependence. Sixty percent (6/10) of the CYC patients and 50% (5/10) of the TAC patients who achieved CR maintained remission during the follow-up period of 23.0 +/- 10.1 months. Four (40%) CYC patients and five (50%) TAC patients experienced relapses, and two CYC patients experienced frequent relapses.

CONCLUSION

A 24-week course of TAC is a favorable steroid-sparing agent for treatment of Chinese adults with SD-MCNS. Therapy with TAC accompanied by a tapering dose of prednisolone appears to yield quicker remission than treatment with CYC together with prednisone.

Early detection and successful treatment of cerebral venous thrombosis associated with minimal change nephrotic syndrome

Although venous thrombosis is a major complication in nephrotic syndrome, cerebral venous thrombosis (CVT) is rarely reported. We describe a 29-year-old male with nephrotic syndrome who suddenly developed headache and nausea. Although computed tomography scan and magnetic resonance imaging detected no abnormal lesions, phase-contrast magnetic resonance venography (PC MRV) demonstrated extensive thrombosis of the superior sagittal sinus. After receiving systemic anticoagulant therapy and oral prednisolone, his neurological symptoms improved dramatically, and complete remission from nephrotic syndrome was achieved. Follow-up PC MRV demonstrated recanalization of the superior sagittal sinus, and renal biopsy confirmed the diagnosis of minimal change nephrotic syndrome. Although CVT is difficult to detect with conventional diagnostic methods, PC MRV may help the establishment of an early diagnosis and prompt treatment for a successful outcome.