What is the treatment for Minimal Change Disease (MCD)?

Treatment of Minimal Change Disease (MCD)

Corticosteroids are the first-line treatment for initial episodes of Minimal Change Disease, with a recommended dose of prednisone or prednisolone 1 mg/kg/day (maximum 80 mg) for 4-16 weeks. 1

Initial Treatment Algorithm

First Episode of MCD

1. Initial therapy:

   • Prednisone/prednisolone 1 mg/kg/day (maximum 80 mg) or 2 mg/kg on alternate days (maximum 120 mg) 1
   • Continue high-dose corticosteroids for:
     • Minimum 4 weeks if complete remission achieved
     • Maximum 16 weeks if complete remission not achieved 1

2. After achieving remission:

   • Begin tapering 2 weeks after complete remission 1
   • Taper slowly over a total period of up to 6 months 1

3. For patients with contraindications to corticosteroids (uncontrolled diabetes, psychiatric conditions, severe osteoporosis):

   • Consider calcineurin inhibitors (CNIs) or cyclophosphamide as first-line therapy 1
   • Cyclosporine: 3-5 mg/kg/day in divided doses
   • Tacrolimus: 0.05-0.1 mg/kg/day in divided doses
   • Target blood levels for cyclosporine: 80-120 ng/ml 1, 2

Management of Relapses

For Infrequent Relapses

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

For Frequent Relapses or Steroid-Dependent Disease

1. Cyclophosphamide:

   • Dose: 2-2.5 mg/kg/day for 8 weeks 1
   • Effective in inducing longer remissions 1, 2
   • Caution: Avoid in patients wishing to preserve fertility 2

2. Calcineurin inhibitors:

   • Cyclosporine: 3-5 mg/kg/day in divided doses
   • Tacrolimus: 0.05-0.1 mg/kg/day in divided doses
   • Continue for 1-2 years, then taper slowly 1, 2
   • For subsequent relapses while on CNIs: temporarily increase dose until remission, then taper 2

3. Mycophenolate mofetil (MMF):

   • Dose: 500-1000 mg twice daily for 1-2 years 1
   • Consider for patients intolerant of steroids, cyclophosphamide, and CNIs 2

4. Rituximab:

   • Consider as first choice in younger patients who wish to preserve fertility 2

Special Considerations

MCD with Acute Kidney Injury

• Treat with renal replacement therapy as indicated
• Continue corticosteroids as for first episode of MCD 1

Monitoring During Treatment

1. Efficacy monitoring:

   • Regular assessment of proteinuria (target: complete remission <0.3 g/day)
   • Kidney function tests

2. Drug-specific monitoring:

   • For CNIs: Blood levels, kidney function, blood pressure
   • For cyclophosphamide: Complete blood count, liver function
   • For all immunosuppressants: Monitor for infections

Common Pitfalls to Avoid

1. Too rapid tapering of immunosuppression leading to early relapse 2
2. Inadequate duration of therapy, especially with CNIs (should be continued for at least 12 months after remission) 1, 2
3. Failure to monitor for drug-specific toxicities:
   • Cyclosporine: Gingival hypertrophy, hypertrichosis
   • Tacrolimus: Diabetes, glucose intolerance
   • Both CNIs: Risk of kidney scarring with long-term use 1
4. Brand switching with cyclosporine without careful monitoring of drug levels 1

Prognosis

The long-term prognosis for patients with MCD is excellent, with fewer than 5% progressing to end-stage renal disease 3. However, relapses are common, occurring in up to 85% of adult patients, with higher frequency in younger adults (<45 years) and often within the first 6-12 months after remission 3.

Recent research suggests that tacrolimus monotherapy can be an effective alternative for patients wishing to avoid steroid therapy, with similar remission rates at 8,16, and 26 weeks compared to prednisolone 4.