Case Studies
Case 9.8 Minimal-change nephropathy
An 8-year-old girl presented with a 3-day history of swelling of the legs and puffiness around the eyes following a cold 1 week earlier. She had some mild abdominal discomfort and a headache for 2 days. Examination revealed a generally oedematous girl with ascites and a blood pressure of 120/70. Her height was on the 50th centile but her weight was above the 90th centile. Urinalysis showed marked proteinuria with moderate haematuria. Her haemoglobin, white-cell count and urea and electrolytes were normal but there was marked hypoalbuminaemia (11g/l) and proteinuria (26g/day). The urinary clearance of IgG relative to that of transferrin was less than 0.1, indicating highly selective proteinuria. Creatinine clearance, CH50, C4 and C3 levels were all normal. A throat swab grew commensal flora only and the antibody titre to streptococcal antigens was normal.
Highly selective proteinuria in a child with the nephrotic syndrome is virtually diagnostic of minimal-change nephropathy. For this reason, renal biopsy was not performed but a trial of steroid therapy (prednisolone 60mg/day) was started with dramatic effect. Over the next week, her serum albumin rose to 26g/l and the proteinuria subsided. At discharge, only a trace of proteinuria was detectable but she continued to take 40mg prednisolone on alternate days for a further 3 months. The nephrotic syndrome did not relapse when steroids were withdrawn.
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