Minimal change nephropathy: an update (for adults) Dr. CC Szeto Department of Medicine & Therapeutics The Chinese University of Hong Kong

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1 Minimal change nephropathy: an update (for adults) Dr. CC Szeto Department of Medicine & Therapeutics The Chinese University of Hong Kong

2 First, it is not uncommon Cameron JS. Am J Kidney Dis 10: , 1987

3 How about Hong Kong? overall prevalence: 33.2% Ng JK, et al. Nephrology (in press).

4 Possible even in non-nephrotic proteinuria overall prevalence: 3.5% Ng JK, et al. Nephrology (in press).

5 Secondary causes are increasingly recongized allergens: pollen, bee sting, food allergens malignancies, e.g. Hodgkin disease, solid tumor drugs NSAID tyrosine kinase inhibitors salazopyrin, penicillamine, lithium mercury?, gold? infections, e.g. viral autoimmune SLE others, e.g. myasthenia gravis, celiac disease Waldman M, et al. Clin J Am Soc Nephrol 2: , 2007 Vivarelli M, et al. Clin J Am Soc Nephrol 12: , 2017.

6 Time to response is much longer Vivarelli M, et al. Clin J Am Soc Nephrol 12: , 2017.

7 Some patients never respond 125 patients from 10 centers onset in adulthood or late adolescence Rutger J. Maas, et al. Am J Kidney Dis. 2017;69(5):

8 AKI is not uncommon at presentation no AKI AKI P value no. of case 75 (60%) 50 (40%) age 41 (28-52) 55 (42-72) p < HT 19 (25%) 27 (54%) p = serum albumin (g/l) 21 (17-25) 18 (15-23) p = 0.06 proteinuria (g/day) 7.5 ( ) 12.4 ( ) p < Rutger J. Maas, et al. Am J Kidney Dis. 2017;69(5):

9 Risk of relapse is high Rutger J. Maas, et al. Am J Kidney Dis. 2017;69(5):

10 KDIGO treatment recommendation first episode prednisolone 1 mg/kg per d or 2 mg/kg every other d (max 80 mg/d or 120 mg every other d) for 4 16 wk (level 2C) taper slowly over a total period of up to 6 mo after achieving remission (level 2D) infrequent relapses 1 mg/kg per d or 2 mg/kg every other d (max 80 mg/d or 120 mg every other d) for 4 16 wk (level 2C) taper slowly over a total period of up to 6 mo after achieving remission (level 2D) KDIGO glomerulonephritis workgroup. Kidney Int 2[Suppl. 2]: , 2012

11 Second line agents frequent relapses and steroid dependency CP mg/kg per d for 8 wk (single course) (level 2C) if relapse occurs despite CP or to preserve fertility: CyA 3 5 mg/kg per d in two doses for 1 2 yr (level 2C), or TAC mg/kg per d in two doses until 3 mo after remission, then tapered to the min efficient dose for 1 2 yr (level 2C) if intolerant to all of the above: MMF mg twice daily for 1 2 yr (level 2D) KDIGO glomerulonephritis workgroup. Kidney Int 2[Suppl. 2]: , 2012

12 MMF: may not be quite as good 60 children with steroid resistant nephrotic syndrome RCT: tacrolimus vs MMF MMF FK P value no. of case favorable outcome treatment failure p = p = Sinha A, et al. Kidney International (2017) 92,

13 Rituximab 10 children and 20 adults MCD/MesGN (n = 22) or FSGS (n = 8) 1 dose (n = 28) or 2 doses of rituximab (375 mg/m2) Ruggenenti P, et al. J Am Soc Nephrol Apr;25(4):

14 Effect on B cell or podocyte? after rituximab, some patients maintain prolonged remission despite reconstitution of B cells rituximab binds directly to podocyte SMPDL3b and antiproteinuric effect may be independent of B cell depletion Fornoni A, et al. Sci Transl Med Jun 1;3(85):85ra46.

15 Local data 340 consecutive adult patients with nephrotic syndrome and biopsy-proven MCN treated from 1984 to 2004 treatment response groups: primary steroid resistance frequent relapse ( 4 relapses within 1 year) infrequent relapse ( 1 relapse but not frequent relapse) no relapse (reference group) outcome measures medical problems after diagnosis patient survival renal survival Szeto CC, et al. Am J Kidney Dis. 2015;65:710-8.

16 Clinical characteristics no relapse infreq relapse freq relapse resistant no. of patients sex (M:F) 90:89 23:19 64:22 13:20 age at diagnosis (years) 39.1 ± ± ± ± 15.5 range feature at presentation proteinuria (g/day) 4.9 ( ) 4.0 ( ) 5.3 ( ) 4.2 ( ) estimated GFR 93 (74 110) 99 (83 136) 101 (82 132) 34 (16 51) microscopic hematuria 43 (24.0%) 8 (19.0%) 20 (23.3%) 6 (18.2%) high blood pressure 28 (15.6%) 8 (19.0%) 14 (16.3%) 20 (60.6%) acute kidney injury 18 (10.1%) 0 7 (8.1%) 23 (69.7%) Szeto CC, et al. Am J Kidney Dis. 2015;65:710-8.

17 Clinical characteristics no relapse infreq relapse freq relapse resistant no. of patients time to remission ( weeks) 10 (8 12) 11 (8 14) 12 (10 12) - second line treatment cyclophosphamide (61.6%) 5 (15.2%) cyclosporine 2 (1.1%) 0 36 (41.9%) 8 (24.2%) levamisole (10.5%) 0 second kidney biopsy total 29 (16.2%) 12 (28.6%) 31 (36.1%) 12 (36.3%) MCN FGS Szeto QI CC, et al. Am J Kidney Dis. 2015;65:

18 Overall outcome Szeto CC, et al. Am J Kidney Dis. 2015;65:710-8.

19 Renal function loss? Szeto CC, et al. Am J Kidney Dis. 2015;65:710-8.

20 Patient survival Szeto CC, et al. Am J Kidney Dis. 2015;65:710-8.

21 Long term complications all patients no relapse infreq relapse frequent resistant no. of cases any problem 185 (54.4%) 82 (45.8%) 21 (50.0%) 53 (61.6%) 29 (87.9%) diabetes b 60 (17.6%) 30 (16.8%) 3 (7.1%) 16 (18.6%) 11 (33.3%) hypertension b 139 (40.9%) 57 (31.8%) 17 (40.5%) 37 (43.0%) 28 (84.8%) CVD 37 (10.9%) 13 (7.3%) 2 (4.8%) 8 (9.3%) 14 (42.4%) CVA 23 (6.8%) 10 (5.6%) 3 (7.1%) 4 (4.7%) 6 (18.2%) persistent UP 44 (12.9%) 14 (7.8%) 8 (19.0%) 19 (22.1%) 3 (9.1%) Szeto CC, et al. Am J Kidney Dis. 2015;65:710-8.

22 Non-cardiovascular complicaitons all patients no relapse infreq relapse frequent resistant no. of cases AVN 6 (1.8%) 2 (1.1%) 1 (2.4%) 3 (3.5%) 0 any fracture 24 (7.1%) 9 (5.0%) 2 (4.8%) 13 (15.1%) 0 peptic ulcer 13 (3.8%) 9 (5.0%) 1 (2.4%) 2 (2.3%) 1 (3.0%) DVT / PE 10 (2.9%) 5 (2.8%) 1 (2.4%) 3 (3.5%) 1 (3.0%) any cancer 35 (10.3%) 15 (8.4%) 2 (4.8%) 7 (8.1%) 11 (33.3%) major infections 17 (5.0%) 5 (2.8%) 2 (4.8%) 5 (5.8%) 5 (15.2%) hepatitis B flare c 15 (4.4%) 5 (2.8%) 0 7 (8.1%) 3 (9.1%) Szeto CC, et al. Am J Kidney Dis. 2015;65:710-8.

23 Complication: another recent series 125 cases Rutger J. Maas, et al. Am J Kidney Dis. 2017;69(5):

24 Other published literature feature at presentation first episode relapse author no. mic HU HT AKI remission at 8 weeks steroid resistance never infreq freq Nolasco et al 89 60% 19% 24% 56% 21% Korbet et al 40 21% 21% 18% 52.5% 9% 32.3% Mak et al 51 33% 47% 55% 70% 8% Huang et al 46 13% 13% 35% 80% 6% 56% Nakayama et al % 1.6% 24.2% 53.2% 21.0% Tse et al 50 90% 4% 46% Waldman et al % 25% 20% 33.8% 21% present study % 20.6% 14.1% 30.9% 9.7% 52.7% 12.4% 25.3% Szeto CC, et al. Am J Kidney Dis. 2015;65:710-8.

25 Paediatric cases going into adulthood 55 paediatric patients with biopsy-proved MCN 35 were followed after age 18 years 13 (37%) had relapses during adulthood 20 (57%) had treatment-related complications none had persistent abnormal kidney function Kwong VW, et al. Hong Kong J Nephrol 2013; 15:

26 All kinds of complication are possible Kwong VW, et al. Hong Kong J Nephrol 2013; 15:

27 Conclusion MCN in adult should not be taken lightheartedly many have secondary causes takes longer to respond to steroid AKI is common at presentation rate of complication, including delayed ones, is high some, esp. those resistant to steroid, may progress to dialysis-dependent renal failure

28 Acknowledgement Dr. Terry Ma Dr. Jack Ng Dr. Vickie Kwong Prof. Fernand Lai Ms. Phyllis Cheng Ms. Cathy Luk Division of Nephrology, Department of Medicine & Therapeutics, Prince of Wales Hospital, CUHK