Kidney Week

Abstract: PUB183

Dialysis Recovery and Sustained Remission After Biopsy-Informed Multimodal Immunosuppression in Steroid Refractory Adult Minimal Change Podocytopathy

Session Information

• Publication Only

Category: Glomerular Diseases

• 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics

Authors

• Tijerina, Diego, South Texas Health System, Edinburg, Texas, United States

Diego Tijerina, MD

• EL-Najjar, Yassin, South Texas Health System, Edinburg, Texas, United States

Yassin EL-Najjar, MD

• Touma, Mary-Joe, South Texas Health System, Edinburg, Texas, United States

Mary-Joe Touma, MD

• Alsabbagh, Mourad, South Texas Health System, Edinburg, Texas, United States

Mourad Alsabbagh, MD

Introduction

Dialysis-requiring AKI in adult minimal change disease (MCD) is uncommon and raises concern for irreversible kidney failure when imaging suggests chronic parenchymal disease, dialysis is prolonged, or corticosteroids fail — and KDIGO 2021 provides no guidance for steroid-refractory adult MCD. Biopsy-defined chronicity and targetable injury pattern may guide both prognosis and therapeutic escalation.

Case Description

A 63-year-old woman with rheumatoid arthritis on chronic prednisone since 1987 presented with anasarca, ~50-lb weight gain, hypoalbuminemia (2.0 g/dL), nephrotic proteinuria (UPCR ~9,000–10,000 mg/g), and dialysis-requiring AKI (Cr 7.7 mg/dL). Ultrasound showed bilaterally small, echogenic kidneys (R 8.7 cm;L 9.2 cm). Biopsy revealed MCD with diffuse foot-process effacement, coexisting mesangial IgA nephropathy (Oxford M0E0S0T0C0), ATI, and only ~5% IFTA; podocyte IgG "dusting" suggested anti-nephrin–associated injury. Despite chronic corticosteroid use, the patient developed fulminant MCD, suggesting functional steroid refractoriness from onset; a one-week trial of prednisone 100 mg daily confirmed lack of early response. Given biopsy-defined minimal chronicity, tacrolimus, mycophenolate, and three doses of rituximab were initiated with prednisone. Hemodialysis was stopped after ~90 days. Albumin normalized (4.0–4.1 g/dL), Cr improved to 1.0 mg/dL, eGFR recovered to 59 mL/min/1.73m2, and proteinuria entered complete remission (UPCR 53 mg/g at 4 months; UACR 7 mg/g at 9 months). Remission has been sustained on mycophenolate after tacrolimus withdrawal.

Discussion

Severe functional collapse coexisted with minimal structural damage (~5% IFTA, no segmental sclerosis). In NEPTUNE, median IFTA in MCD was 1%, and each 10% fibrosis increase predicted eGFR decline (HR 1.29); ~5% IFTA here indicated recoverable disease, contradicting imaging. Teaching points: (1) biopsy-defined chronicity may be more decisive than diagnostic classification when imaging suggests irreversibility; (2) MCD onset during chronic corticosteroid therapy represents functional steroid refractoriness, not addressed by KDIGO definitions —early steroid-sparing escalation is rational; (3) anti-nephrin–suggestive IgG dusting may support B-cell–targeted therapy, extending biopsy from diagnostic to theranostic; (4) renal recovery in MCD-AKI tracks proteinuric remission.