S DANG1, R GATELY1,3, K JOHNSTONE2, D W MUDGE1,3
1Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Australia, 2Department of Anatomical Pathology, Princess Alexandra Hospital, Woolloongabba, Australia, 3Faculty of Medicine, University of Queensland, St Lucia, Australia
Background: Nephrotic syndrome (NS) is often associated with malignancy. Minimal change disease (MCD) is the leading cause of NS in children (70-90%) and a less common cause of NS in adults (10-15%). Traditionally, solid tumours have been associated with membranous nephropathy (MN) in older adults while haematological malignancies are linked to MCD in younger adults. The association between MCD and solid tumours has rarely been described in literature.
Case Report: We describe a 61-year-old male who presented with NS. Further workup indicated hepatocellular carcinoma (HCC) in the absence of other risk factors. He underwent simultaneous kidney biopsy and surgical resection of the malignancy 8 weeks later. The kidney biopsy suggested MCD as it showed normal glomeruli without segmental sclerotic lesions, negative immunofluorescence, no glomerular basement membrane deposits and effacement of podocyte foot processes on electron microscopy. The patient achieved complete remission of NS 6 weeks after surgery.
Conclusions: There are limited cases of MCD associated with solid tumours in older patients (mean age=64) described in the literature. The tumour type varies, however thymoma and carcinoma seem to be most common. The general disease course is that partial or complete remission of NS is achieved after treatment of the tumour (with chemotherapy, radiotherapy or surgery). Systemic corticosteroids or other immunosuppressive therapies (e.g. mycophenolate) appear to have minimal effect. To our knowledge, this is the first description of MCD associated with HCC. The pathophysiology of this phenomenon is not clearly understood, however the temporal relationship between tumour treatment and remission of MCD suggests an association between these disease processes. Therefore, it may be important to consider tumour screening in older adults with a new diagnosis of MCD.
Dr Sanjana Dang is currently a Basic Physician Trainee in Brisbane. She graduated from Griffith University in 2016 and completed her residency with a focus on critical care at the Gold Coast University Hospital from 2017 to 2019. After commencing work in Brisbane at the Princess Alexandra Hospital, she cemented her strong interest in General Nephrology and wishes to apply for the Nephrology Advanced Trainee Network after sitting her exams in 2021. She is also an executive member of the Royal Australasian College of Physicians QLD Trainees committee and is passionate about the advocacy and wellbeing of junior doctors.