When Minimal Becomes Massive - A Case Report of Childhood-Onset Minimal Change Disease Marching to End Stage Renal Disease Despite Modern Immunotherapy

Sep 29, 2026

Rare childhood-onset Minimal Change Disease (MCD) case in a 31-year-old man diagnosed at 2.5 years with nephrotic syndrome. Serial biopsies confirmed pure MCD: near-normal glomeruli on light microscopy and diffuse podocyte foot-process effacement on electron microscopy. Despite repeated relapses, prolonged corticosteroids, and adjunct immunosuppression including cyclosporine, tacrolimus, and two Rituximab courses, progressive decline culminated in ESRD and maintenance hemodialysis in August 2025, with an ischemic stroke at age 20. Highlights aggressive phenotype, requiring long-term monitoring.

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Abstract

Introduction

Case Presentation

Laboratory Findings on Admission (August 2025)

When Minimal Becomes Massive: A Case Report of Childhood-Onset Minimal Change Disease Marching to End Stage Renal Disease Despite Modern Immunotherapy Momen Zetawi 1, Hossam Salameh 1, Malak K. Assi 1, Shahd Aldarak 1 and Safa’Ramez Altiti2 Clinical Medicine Insights: Case Reports Volume 19: 1–4 © The Author(s) 2026 Article reuse guidelines: [sagepub.com/journals-permissions](sagepub.com/journals-permissions)[ ](sagepub.com/journals-permissions)[DOI: 10.1177/11795476251413414](DOI: 10.1177/11795476251413414)[ ](DOI: 10.1177/11795476251413414)[journals.sagepub.com/home/icr](journals.sagepub.com/home/icr) Abstract We report a rare case of childhood-onset Minimal Change Disease (MCD) in a 31-year-old male, originally diagnosed at age 2.5 with nephrotic syndrome. Repeated biopsies throughout his childhood and adolescence revealed normal glomeruli on light microscopy and diffuse effacement of podocyte foot processes on electron microscopy, confirming pure MCD. Despite multiple relapses, prolonged corticosteroid therapy, and adjunctive immunosuppressants including cyclosporine, tacrolimus, and 2 courses of Rituximab, the patient developed progressive renal decline culminating in end-stage renal disease (ESRD) and initiation of maintenance hemodialysis in August 2025. His course also included an ischemic stroke at age 20. This case illustrates an atypical, aggressive phenotype of MCD, without transformation to focal segmental glomerulosclerosis, that challenges the conventional prognosis of MCD and underscores the need for long-term monitoring and reporting of such exceptional cases. Keywords minimal change disease, steroid-dependent nephrotic syndrome, end-stage renal disease, podocytopathy, refractory glomerular disease Received: 7 November 2025; accepted: 18 December 2025 Introduction Minimal change disease (MCD) is the leading cause of idiopathic nephrotic syndrome in children, accounting for roughly 70% to 90% of cases in children older than 1 year, but is much less common in adults (approximately 10% - 15%) .1 MCD is a podocytopathy characterized histologically by near-normal glomeruli on light microscopy and diffuse effacement of podocyte foot processes on electron microscopy.1 Podocyte dysfunction, including alterationsin nephrin and other slit-diaphragm proteins, and immunemediated circulating factors have been implicated in its pathogenesis; recent studies have described circulating anti-nephrin autoantibodies in a subset of patients with active disease.1 Nephrotic syndrome, characterized by periorbital, scrotal, labial, and lower limb edema, is the most common presenting manifestation of minimal change disease (MCD) .1 The edema results from decreased oncotic pressure, leading to ascites, pleural and pericardial effusions, and ultimately anasarca. In many cases, these symptoms are preceded by an upper respiratory tract infection.1 Most patients, particularly children, respond to corticosteroids and have a favorable prognosis; however, relapses are common, and a minority develop steroid-dependence or steroid-resistance, necessitating second-line immunosuppression such as calcineurin inhibitors or biologic therapies (eg, rituximab) .2 Although the use of rituximab was confirmed for refractory MCD, and complete remission at a higher rate, there are still reported incidence where relapse can still occur according to Feder et al.3,4 We report a 31-year-old man with childhood-onset MCD who progressed to ESRD despite prolonged corticosteroids 1 Department of Medicine, An-Najah National University, Nablus, Palestine 2Internal Medicine Specialist, British Medical Health Centre for Hemodialysis, Nablus, Palestine Corresponding author: Hossam Salameh, Department of Medicine, An-Najah National University, Rafidia Street, Nablus P400, Palestine. Email: [slamthsam@gmail.com](slamthsam@gmail.com) Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Com

FAQs

How was the childhood-onset Minimal Change Disease diagnosis confirmed in this case?

Diagnosis was confirmed through repeated biopsies showing normal glomeruli on light microscopy and diffuse podocyte foot-process effacement on electron microscopy, consistent with pure MCD.

Which treatments were used before the patient reached end-stage renal disease?

The patient received prolonged corticosteroids with multiple relapses, along with adjunctive immunosuppressants including cyclosporine, tacrolimus, and two courses of Rituximab.

What clinical outcome did the case ultimately reach despite modern immunotherapy?

Progressive renal decline culminated in end-stage renal disease and initiation of maintenance hemodialysis in August 2025.

Sep 29, 2026

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