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Kidney Week

Abstract: PO1907

A New Approach to De Novo Minimal Change Disease in Pregnancy

Session Information

Category: Trainee Case Report

  • 1203 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Gleeson, Sarah, Imperial Healthcare NHS Trust, London, United Kingdom
  • Cardoso, Filipa, Imperial Healthcare NHS Trust, London, United Kingdom
  • Lightstone, Liz, Imperial Healthcare NHS Trust, London, United Kingdom
  • Cairns, Tom, Imperial Healthcare NHS Trust, London, United Kingdom
Introduction

Although proteinuria in pregnancy is common and usually due to preeclampsia, nephrotic range proteinuria especially early in pregnancy, warrants investigation and treatment. We present the first case of minimal change disease (MCD) presenting in pregnancy, treated only with tacrolimus.

Case Description

A previously well 20 year old G1P0, presented at 9 weeks gestation with 3 weeks of oedema and shortness of breath. Examination revealed marked oedema.
Investigations: creatinine 44umol/L (55-110), albumin 7g/L (35-50), urine PCR 1456mg/mmol. A fetal scan confirmed a viable pregnancy. A renal biopsy was performed which demonstrated MCD. She was started on tacrolimus in addition to enoxaparin, frusemide and aspirin. At 12 weeks she had melena with a haemoglobin drop. There was no active bleeding on endoscopy and she had no further episodes in pregnancy.
She was managed by the renal and joint renal-obstetric clinic throughout pregnancy. She was maintained on tacrolimus alone (levels 5-8ug/L). Her albumin rose and PCR fell throughout pregnancy. By 34 weeks her albumin was 28g/L and uPCR was 128 mg/mmol. Fetal growth was normal on serial growth scans. She did not develop preeclampsia. Labour was induced at 39 weeks and she had a normal vaginal delivery of a 3194g healthy baby

Discussion

There have only been 4 previous reports of de novo MCD in pregnancy all of whom were treated with steroids. In our patient who presented early in pregnancy with marked oedema and heavy proteinuria a kidney biopsy was performed.Kidney biopsy should be performed when the benefit of obtaining a diagnosis outweighs the risks of the procedure. In pregnancy the risks are increased (7% versus 1% outside pregnancy). Biopsy during the 1st trimester is safest.
Corticosteroids are often used to treat MCD outside pregnancy. Prednisone is safe is pregnancy as the fetal dose is minimal. However, there is a risk of maternal complications including gestational diabetes and weight gain.
The recent MinTac trial of prednisolone and tacrolimus in patients with MCD found no difference in remission rates at 8, 16 or 26 weeks and no difference in relapse rates. We achieved partial remission in this heavily nephrotic patient with use of tacrolimus alone allowing us to avoid steroid adverse effects, which was especially important after her GI bleed. We believe tacrolimus is a valuable option for treatment of MCD in pregnancy.