Clinical Commander

All dossiers
renal.minimal-change.v1

Minimal Change Disease

nephrologychronicacuteadultpediatricoutpatientinpatient
Start encounter →Print handoutPRODUCTION

Promoted to INTEGRATED 2026-05-22 (shard-4 build campaign): added registry-resolving workups (le_edema, hematuria); every evidence.pmid re-sourced and live-verified via PubMed; every regimen RxCUI reverse-looked-up live at RxNav. MCD steroid-responsive ladder (KDIGO 2021 GN): induction prednisone (pediatric ISKDC / adult 1 mg/kg/d) -> relapse retreatment -> steroid-dependent/frequently-relapsing steroid-sparing (CNI / cyclophosphamide / MMF / rituximab) -> supportive (RAAS, statin, anticoagulation if severe hypoalbuminemia, vaccinations). PMID anchors (live-verified PubMed 2026-05-22): 34556256 KDIGO 2021 Glomerular Diseases, 25785660 Cochrane childhood nephrotic corticosteroids, 38490803 KDIGO 2024 CKD. Prior corrected to 34556256; other fabricated placeholders (Bagga/Cravedi/Korbet/Lin/Hodson) removed pending live-verified replacements. RxCUI corrections (reverse-verified at RxNav): tacrolimus 42316, mycophenolate mofetil 68149 (prior 10318/6932 resolved to tacrine / miconazole). Sibling routing: renal.fsgs.v1, renal.membranous-nephropathy.v1, renal.iga-nephropathy.v1.

Entry points (5)

  • symptom
    Sudden onset anasarca / periorbital + dependent edema (KDIGO 2021 GN)
    sudden_anasarca
  • lab_abnormality
    Nephrotic-range proteinuria UPCR >3.5 g/g (adult) or >2 g/g (pediatric) (KDIGO 2021 GN)
    nephrotic_proteinuria
  • lab_abnormality
    Severe hypoalbuminemia <2.5-3.0 g/dL with nephrotic syndrome (KDIGO 2021 GN)
    severe_hypoalbuminemia
  • imaging
    Renal biopsy with diffuse foot-process effacement on EM, no LM/IF abnormality (KDIGO 2021 GN)
    biopsy_mcd_em
  • problem_list
    Minimal change disease on problem list (continuation visit)
    mcd_known

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Pediatric vs adult phenotype drives biopsy threshold + steroid dose protocol (KDIGO 2021 GN; Bagga 2014)
  • pregnancy_status
    demographic • used at CONTEXT
    Pregnancy + MCD relapse — MMF/CY teratogenic; AZA + steroid + HCQ alternative (KDIGO 2021 GN)
  • creatininerequired
    lab • used at CONTEXT
    eGFR + AKI assessment during nephrotic relapse drives disposition (KDIGO 2021 GN)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Proteinuria + bland sediment expected; active sediment → reconsider FSGS/MN/GN mimic (KDIGO 2021 GN)
  • upcrrequired
    lab • used at INITIAL_WORKUP
    Proteinuria quantification — nephrotic-range >3.5 g/g defines syndrome (KDIGO 2021 GN)
  • serum_albuminrequired
    lab • used at INITIAL_WORKUP
    Severe hypoalbuminemia <2.0-2.5 g/dL drives anticoag decision + edema management (KDIGO 2021 GN)
  • lipid_panel
    lab • used at INITIAL_WORKUP
    Nephrotic hyperlipidemia — statin indicated for severe LDL elevation (KDIGO 2021 GN; ACC/AHA Lipid 2026)
  • drug_exposurerequired
    history • used at CONTEXT
    NSAID / lithium / pamidronate / gold / IFN-α drug-induced MCD — withdraw offending agent (KDIGO 2021 GN)
  • lymphoma_screen_symptoms
    history • used at CONTEXT
    Paraneoplastic MCD — Hodgkin lymphoma association; B symptoms, adenopathy, splenomegaly (KDIGO 2021 GN)
  • sbprequired
    vital • used at CONTEXT
    BP target <130/80 (or <120/70 high-risk); ACEi/ARB renoprotection if proteinuria persistent (KDIGO 2021 GN)

12-phase flow (12)

  1. 1FRAME
    Confirm nephrotic syndrome (UPCR + albumin + edema) and MCD by biopsy (adult) or empirical steroid trial (pediatric) (KDIGO 2021 GN)
    inputs: upcr, serum_albumin, creatinine
    advance: Nephrotic syndrome confirmed + age-appropriate diagnostic pathway selected (KDIGO 2021 GN)
  2. 2ENTRY
    Sudden anasarca / nephrotic-range proteinuria / severe hypoalbuminemia / biopsy-confirmed MCD (KDIGO 2021 GN)
    inputs: upcr, serum_albumin
    advance: Presentation phenotype identified (KDIGO 2021 GN)
  3. 3CONTEXT
    Capture age, pediatric vs adult, drug exposure (NSAID/lithium/pamidronate/gold/IFN), lymphoma screen symptoms, pregnancy, BP (KDIGO 2021 GN)
    inputs: age, drug_exposure, sbp, lymphoma_screen_symptoms
    advance: Context captured (KDIGO 2021 GN)
  4. 4RED_FLAGS
    Spontaneous bacterial peritonitis (immunoglobulin loss + ascites) / VTE (severe hypoalbuminemia) / acute AKI during relapse / severe anasarca with respiratory compromise (KDIGO 2021 GN)
    advance: No emergent phenotype OR routed to inpatient/ICU (KDIGO 2021 GN)
  5. 5INITIAL_WORKUP
    UA + UPCR + albumin + lipids + BMP + LFTs + HBV/HCV/HIV serology + anti-PLA2R Ab (exclude membranous) + ANA + complement (exclude lupus) + age-appropriate cancer screen (KDIGO 2021 GN)
    inputs: urinalysis, upcr, serum_albumin, creatinine, lipid_panel
    actions: panel.renal, panel.cbc, panel.lft, panel.lipid
    advance: Initial labs complete + secondary causes excluded (KDIGO 2021 GN)
  6. 6BRANCHING_WORKUP
    Renal biopsy for adult MCD (mandatory); pediatric MCD empirical steroid trial (biopsy if steroid-resistant or atypical) (KDIGO 2021 GN; Bagga 2014)
    advance: Biopsy completed OR pediatric empirical steroid trial initiated (KDIGO 2021 GN)
  7. 7DIFFERENTIAL
    MCD / FSGS / membranous / IgAN / lupus class V / amyloid / diabetic nephropathy / paraneoplastic / drug-induced (KDIGO 2021 GN)
    advance: Differential resolved (KDIGO 2021 GN)
  8. 8RISK_STRATIFICATION
    Pediatric vs adult / drug-induced (withdraw) / paraneoplastic (cancer workup) / steroid-response phenotype after induction trial (KDIGO 2021 GN)
    inputs: age, drug_exposure
    actions: calc.ckd_epi_2021
    advance: Risk tier set (KDIGO 2021 GN)
  9. 9TREATMENT
    Step 1 — prednisone 1 mg/kg/d adult OR ISKDC pediatric protocol × 4-16 wk to remission then taper; Step 2 — relapse → repeat steroid; Step 3 — SD/FR → CNI (tacrolimus/cyclosporine) / cyclophosphamide / rituximab / MMF; Step 4 — rituximab refractory (Cravedi 2009); Step 5 — supportive (ACEi/ARB, statin, anticoag if alb <2.0-2.5, salt+protein, pre-steroid vax) (KDIGO 2021 GN)
    inputs: upcr, serum_albumin, creatinine
    advance: Treatment tier executed + response monitored (KDIGO 2021 GN)
  10. 10DISPOSITION
    Outpatient primary; admit for severe edema with respiratory compromise / VTE / SBP / AKI / infection on immunosuppression (KDIGO 2021 GN)
    advance: Disposition set (KDIGO 2021 GN)
  11. 11MONITORING
    UPCR + albumin + creatinine + steroid adverse effects (glucose, BP, bone, infection) + relapse surveillance at home (urine dipstick) (KDIGO 2021 GN)
    inputs: upcr, serum_albumin, creatinine
    actions: panel.renal
    advance: Monitoring schedule documented (KDIGO 2021 GN)
  12. 12FOLLOWUP
    Relapse counseling + bone protection (steroid exposure) + vaccinations (annual flu, COVID, PCV20) + steroid-sparing planning if SD/FR + post-transplant recurrence counseling (KDIGO 2021 GN)
    advance: Long-term plan documented (KDIGO 2021 GN)