What infections can trigger or exacerbate Minimal Change Disease (MCD) and how are they managed?

From the Guidelines

Infections such as respiratory, urinary tract, and gastrointestinal infections can trigger or exacerbate Minimal Change Disease (MCD), and management involves treating the underlying infection while addressing MCD symptoms with corticosteroids like prednisone (1mg/kg/day, maximum 80mg daily) for 4-16 weeks with gradual tapering, as recommended by the KDIGO 2021 clinical practice guideline for the management of glomerular diseases 1.

Infection Management

• Respiratory infections: appropriate antibiotics (e.g., amoxicillin 500mg three times daily for 7-10 days) or antivirals (e.g., oseltamivir 75mg twice daily for 5 days) based on the specific pathogen.
• Urinary tract infections: antibiotics such as nitrofurantoin (100mg twice daily for 5-7 days) or trimethoprim-sulfamethoxazole (160/800mg twice daily for 3 days).
• Gastrointestinal infections: metronidazole (500mg three times daily for 7-10 days) for bacterial causes or supportive care for viral gastroenteritis.

MCD Management

• Corticosteroids like prednisone (1mg/kg/day, maximum 80mg daily) for 4-16 weeks with gradual tapering, as the first-line treatment for MCD, with approximately 95% of children achieving urinary remission of proteinuria within 4 weeks and complete remission after an 8-week course 1.
• The connection between infections and MCD relates to immune system dysregulation, where infections trigger T-cell activation and cytokine release that damage podocytes in the kidneys, leading to proteinuria.

Patient Care

• Patients should maintain good hydration, monitor urine output and protein levels, and follow up regularly with both infectious disease specialists and nephrologists to ensure complete resolution of both conditions.
• The KDIGO 2021 guideline provides recommendations for the management of glomerular diseases, including MCD, and emphasizes the importance of treating the underlying infection and addressing MCD symptoms simultaneously 1.

From the Research

Infections Associated with Minimal Change Disease

• Hepatitis C virus (HCV) infection has been linked to Minimal Change Disease (MCD) in several case reports, including treatment-naïve HCV infection 2, 3.
• The exact mechanism by which HCV infection triggers or exacerbates MCD is not fully understood, but it is thought to involve immunologic dysregulation and modifications of the podocyte 4.

Management of Infections in Minimal Change Disease

• Treatment of HCV infection with direct antiviral agents, such as ledipasvir and sofosbuvir, has been shown to achieve sustained virological response and remission of nephrotic syndrome in patients with MCD 2.
• Glucocorticoids, such as prednisone, are the mainstay of therapy for MCD, and can be effective in reducing proteinuria and resolving renal failure, even in patients with concomitant HCV infection 2, 3.
• Second-line immunosuppressive agents may be necessary for patients who are steroid-resistant or frequently relapsing, but the choice of agent and treatment strategy should be individualized based on the patient's specific clinical characteristics and response to therapy 5.

Key Considerations

• MCD can present with acute renal failure and nephrotic syndrome, and a thorough diagnostic workup, including renal biopsy, is necessary to establish the diagnosis and guide treatment 4, 2, 5, 3.
• The presence of HCV infection or other underlying conditions should be considered in the diagnostic evaluation and treatment plan for patients with MCD 2, 3.