What is the treatment for minimal change disease?

Treatment of Minimal Change Disease

Corticosteroids are the first-line treatment for minimal change disease, with adults typically receiving prednisone 1 mg/kg/day (maximum 80 mg) for 4-16 weeks depending on response. 1

Initial Treatment Algorithm

First-Line Therapy

• Corticosteroid therapy:
  • Prednisone 1 mg/kg/day (maximum 80 mg daily) or alternate-day dosing of 2 mg/kg (maximum 120 mg) 1
  • Continue high-dose treatment for:
    • Minimum 4 weeks if complete remission is achieved
    • Maximum 16 weeks if complete remission is not achieved 1
  • After remission, taper slowly over a total period of up to 6 months 1

Alternative First-Line Options (for steroid contraindications)

For patients with contraindications to high-dose corticosteroids (uncontrolled diabetes, psychiatric conditions, severe osteoporosis):

• Calcineurin inhibitors (CNIs) 1:
  • Cyclosporine: 3-5 mg/kg/day in divided doses (target trough level 60-150 ng/ml)
  • Tacrolimus: 0.05-0.1 mg/kg/day in divided doses (target trough level 5-10 ng/ml)
  • Recent evidence shows tacrolimus monotherapy can be as effective as prednisone with fewer side effects 2

Management of Relapses

Infrequent Relapses

• Use the same initial dose and duration of corticosteroids as for first episode 1

Frequently Relapsing/Steroid-Dependent MCD

Use one of the following steroid-sparing agents:

1. Cyclophosphamide: 2-2.5 mg/kg/day for 8-12 weeks 1
2. Calcineurin inhibitors 1, 3:
   • Continue for at least 12 months after remission
   • Taper slowly to minimum effective dose
3. Rituximab: Particularly beneficial in younger patients wishing to preserve fertility 3, 4
4. Mycophenolic acid analogs: 500-1000 mg twice daily for 1-2 years 1, 3

Monitoring and Follow-up

• Monitor for complete remission (proteinuria <0.3 g/day)
• For patients on CNIs:
  • Monitor blood levels regularly
  • Consider renal biopsy after 12-24 months of therapy to check for nephrotoxicity, especially if serum creatinine rises >30% above baseline 1
  • If no response after 6 months, stop CNI and consider alternative therapy 1

Special Considerations

Renal Function

• MCD has excellent long-term kidney survival with <5% progressing to end-stage renal disease 4
• In patients with AKI, renal replacement therapy may be needed temporarily while continuing corticosteroid treatment 1

Medication-Specific Considerations

• Cyclophosphamide: Avoid in patients wishing to preserve fertility 3
• Calcineurin inhibitors:
  • Cyclosporine may be preferable in patients at risk for diabetes
  • Tacrolimus may be preferred when cosmetic side effects are a concern 3
  • Bioavailability varies between formulations; avoid brand switching 1

Common Pitfalls

1. Tapering corticosteroids too rapidly
2. Inadequate duration of therapy
3. Failure to monitor for drug-specific toxicities
4. Not considering patient-specific factors (age, fertility concerns, comorbidities)
5. Assuming all cyclosporine formulations are equivalent 1

The prognosis for minimal change disease is excellent when properly treated, with most patients responding to therapy and maintaining normal kidney function long-term.