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renal.minimal-change.v1PRODUCTION
renal.minimal-change.v1

Minimal Change Disease

nephrologychronicacuteadultpediatric
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm nephrotic syndrome (UPCR + albumin + edema) and MCD by biopsy (adult) or empirical steroid trial (pediatric) (KDIGO 2021 GN)

Inputs
3
Actions
0
Advance rule
Set
Advance when

Nephrotic syndrome confirmed + age-appropriate diagnostic pathway selected (KDIGO 2021 GN)

Patient inputs (10)

Pediatric vs adult phenotype drives biopsy threshold + steroid dose protocol (KDIGO 2021 GN; Bagga 2014)

eGFR + AKI assessment during nephrotic relapse drives disposition (KDIGO 2021 GN)

NSAID / lithium / pamidronate / gold / IFN-α drug-induced MCD — withdraw offending agent (KDIGO 2021 GN)

BP target <130/80 (or <120/70 high-risk); ACEi/ARB renoprotection if proteinuria persistent (KDIGO 2021 GN)

Proteinuria + bland sediment expected; active sediment → reconsider FSGS/MN/GN mimic (KDIGO 2021 GN)

Proteinuria quantification — nephrotic-range >3.5 g/g defines syndrome (KDIGO 2021 GN)

Severe hypoalbuminemia <2.0-2.5 g/dL drives anticoag decision + edema management (KDIGO 2021 GN)

Pregnancy + MCD relapse — MMF/CY teratogenic; AZA + steroid + HCQ alternative (KDIGO 2021 GN)

Paraneoplastic MCD — Hodgkin lymphoma association; B symptoms, adenopathy, splenomegaly (KDIGO 2021 GN)

Nephrotic hyperlipidemia — statin indicated for severe LDL elevation (KDIGO 2021 GN; ACC/AHA Lipid 2026)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationalsevereadult_idiopathic_mcd
    Adult-onset idiopathic MCD — biopsy mandatory; slower response to steroid (4-16 wk for first remission) (KDIGO 2021 GN; Korbet)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparaneoplastic_mcd_lymphoma
    Paraneoplastic MCD — Hodgkin lymphoma association; B symptoms + adenopathy + LDH; renal often improves with lymphoma treatment (KDIGO 2021 GN)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresteroid_dependent_or_frequently_relapsing
    Steroid-dependent (relapse on or within 2 wk of taper) OR frequently relapsing (≥2 in 6 mo / ≥4 in 12 mo) — escalate to CNI / CY / rituximab / MMF (KDIGO 2021 GN; Hodson Cochrane)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresteroid_resistant_mcd
    Steroid-resistant MCD — failure to remit after 4 wk pediatric or 16 wk adult induction → REBIOPSY to exclude FSGS / IgM nephropathy / atypical lesion (KDIGO 2021 GN)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverethromboembolic_complication_severe_hypoalbuminemia
    Severe hypoalbuminemia <2.0-2.5 g/dL → high VTE / renal vein thrombosis risk; anticoag prophylaxis indicated (KDIGO 2021 GN; Lin nephrotic anticoag)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinfection_susceptibility_nephrotic
    Nephrotic infection susceptibility — opsonin loss (IgG + factor B) + lymphopenia on steroid; SBP, cellulitis, pneumonia, encapsulated organisms (KDIGO 2021 GN)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_aki_during_relapse
    Acute AKI during nephrotic relapse — hemodynamic from volume contraction, severe proteinuria-related tubular injury, or renal vein thrombosis (KDIGO 2021 GN; KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepediatric_classic_mcd
    Pediatric idiopathic MCD — ~90% steroid-responsive within 4 wk of ISKDC-pattern induction; biopsy reserved for steroid-resistant / atypical (KDIGO 2021 GN; Bagga 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedrug_induced_mcd
    Drug-induced MCD — NSAID (most common), lithium, pamidronate, gold, IFN-α — withdraw offending agent; most resolve without immunosuppression (KDIGO 2021 GN)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

MCD steroid-responsive ladder — induction → relapse → steroid-sparing (CNI/CY/RTX/MMF) → rituximab refractory → supportive bundle (KDIGO 2021 GN; Hodson NIPNS Cochrane; Cravedi adult MCD 2009)
axis: mcd_steroid_responsive_ladderstep step_1_induction_prednisone - Step 1 — Induction prednisone (pediatric ISKDC; adult 1 mg/kg/d × 4-16 wk)
Selected step "Step 1 — Induction prednisone (pediatric ISKDC; adult 1 mg/kg/d × 4-16 wk)" — First episode of biopsy-confirmed (adult) or clinically suspected (pediatric) MCD (KDIGO 2021 GN)
  • prednisone
    first line
    corticosteroid_oral
    Adult: 1 mg/kg PO daily (max 80 mg) × 4-16 wk to remission then 6 wk taper. Pediatric: 60 mg/m²/d (max 60 mg) × 4-6 wk then 40 mg/m² (max 40 mg) every other day × 4-6 wk. • PO • daily
    triggers: first_episode_mcd, relapse
    KDIGO 2021 GN — ~80-90% achieve complete remission; pediatric ISKDC pattern, adult slower (up to 16 wk for first remission)
    rxcui 8640

outpatient playbook — drug actions (8)

  1. 1. prednisone induction
    Adult 1 mg/kg/d (max 80) / pediatric ISKDC • PO • daily
    trigger: First episode or relapse
    KDIGO 2021 GN
  2. 2. tacrolimus or cyclosporine
    Trough-titrated • PO • BID
    trigger: SD/FR phenotype
    KDIGO 2021 GN; Hodson Cochrane
  3. 3. cyclophosphamide PO course
    2 mg/kg/d × 8-12 wk • PO • daily
    trigger: Durable remission target
    KDIGO 2021 GN; NIPNS
  4. 4. rituximab if refractory
    375 mg/m² IV weekly × 4 or 1000 mg × 2 • IV • weekly × 4 or q14d × 2
    trigger: Refractory SD/FR
    Cravedi 2009
  5. 5. MMF fertility-sparing alternative
    1-2 g/d divided BID • PO • BID
    trigger: Fertility preservation priority
    KDIGO 2021 GN
  6. 6. ACEi/ARB max-dose
    Lisinopril 10-40 or losartan 50-100 • PO • daily
    trigger: Persistent proteinuria + HTN
    KDIGO 2021 GN
  7. 7. atorvastatin
    20-40 mg PO daily • PO • daily
    trigger: Severe nephrotic dyslipidemia
    ACC/AHA Lipid 2026
  8. 8. warfarin prophylaxis
    INR-titrated 2-3 • PO • daily
    trigger: Albumin <2.0-2.5 g/dL
    Nephrotic VTE prophylaxis Lin

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Sudden onset anasarca / periorbital + dependent edema (KDIGO 2021 GN); Nephrotic-range proteinuria UPCR >3.5 g/g (adult) or >2 g/g (pediatric) (KDIGO 2021 GN); Severe hypoalbuminemia <2.5-3.0 g/dL with nephrotic syndrome (KDIGO 2021 GN).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Minimal Change Disease** (renal.minimal-change.v1).
Phenotype framing: MCD / FSGS / membranous / IgAN / lupus class V / amyloid / diabetic nephropathy / paraneoplastic / drug-induced (KDIGO 2021 GN)
Scope: Confirm nephrotic syndrome (UPCR + albumin + edema) and MCD by biopsy (adult) or empirical steroid trial (pediatric) (KDIGO 2021 GN)

No severity triggers fired against current inputs.

Plan

Regimen axis: **MCD steroid-responsive ladder — induction → relapse → steroid-sparing (CNI/CY/RTX/MMF) → rituximab refractory → supportive bundle (KDIGO 2021 GN; Hodson NIPNS Cochrane; Cravedi adult MCD 2009)** — step "Step 1 — Induction prednisone (pediatric ISKDC; adult 1 mg/kg/d × 4-16 wk)".
1. prednisone Adult: 1 mg/kg PO daily (max 80 mg) × 4-16 wk to remission then 6 wk taper. Pediatric: 60 mg/m²/d (max 60 mg) × 4-6 wk then 40 mg/m² (max 40 mg) every other day × 4-6 wk. PO daily (corticosteroid_oral, first line) — KDIGO 2021 GN — ~80-90% achieve complete remission; pediatric ISKDC pattern, adult slower (up to 16 wk for first remission)

Setting playbook (outpatient) — Primary management setting — induction → remission → relapse retreatment → SD/FR steroid-sparing → maintenance; q3-6 month nephrology visits; CV + bone + fertility long-term (KDIGO 2021 GN)
2. prednisone induction Adult 1 mg/kg/d (max 80) / pediatric ISKDC PO daily — First episode or relapse (KDIGO 2021 GN)
3. tacrolimus or cyclosporine Trough-titrated PO BID — SD/FR phenotype (KDIGO 2021 GN; Hodson Cochrane)
4. cyclophosphamide PO course 2 mg/kg/d × 8-12 wk PO daily — Durable remission target (KDIGO 2021 GN; NIPNS)
5. rituximab if refractory 375 mg/m² IV weekly × 4 or 1000 mg × 2 IV weekly × 4 or q14d × 2 — Refractory SD/FR (Cravedi 2009)
6. MMF fertility-sparing alternative 1-2 g/d divided BID PO BID — Fertility preservation priority (KDIGO 2021 GN)
7. ACEi/ARB max-dose Lisinopril 10-40 or losartan 50-100 PO daily — Persistent proteinuria + HTN (KDIGO 2021 GN)
8. atorvastatin 20-40 mg PO daily PO daily — Severe nephrotic dyslipidemia (ACC/AHA Lipid 2026)
9. warfarin prophylaxis INR-titrated 2-3 PO daily — Albumin <2.0-2.5 g/dL (Nephrotic VTE prophylaxis Lin)

Non-pharmacologic actions:
- Annual vaccination per ACIP 2026 — flu, COVID, PCV20, HBV; AVOID live on immunosuppression (KDIGO 2021 GN)
- Pre-steroid PCV20 + HBV if time permits (KDIGO 2021 GN)
- Contraception + pre-conception planning (switch MMF→AZA 3-6 mo pre-conception) (KDIGO 2021 GN)
- Bone health Ca + vit D + bisphosphonate per FRAX on long-term steroid (KDIGO 2021 GN)
- CV-risk modification — statin per ACC/AHA Lipid 2026 (KDIGO 2021 GN)
- Cancer surveillance on long-term immunosuppression (KDIGO 2021 GN)
- Adult paraneoplastic workup — CT chest/abd/pelvis, peripheral smear, LDH, lymph-node exam if features present (KDIGO 2021 GN)
- Patient action card — relapse red-flags reinforced (KDIGO 2021 GN)

AVOID / contraindication checks:
- Steroid pjp prophylaxis and bone health and glucose monitoring (KDIGO 2021 GN)
- Cy fertility counseling bladder toxicity mesna (KDIGO 2021 GN)
- Cni bp egfr monitoring magnesium interactions (KDIGO 2021 GN)
- Rituximab hbv screen vaccinate pre no live vaccines (KDIGO 2021 GN)
- Mmf teratogenic pregnancy prevention (KDIGO 2021 GN)
- Warfarin inr monitoring bleeding risk (Lin nephrotic anticoag)
- Tmp smx prophylaxis on induction (KDIGO 2021 GN)
- Vaccinate pre steroid no live on immunosuppression (KDIGO 2021 GN)

Monitoring

Regimen monitoring:
- UPCR + serum albumin + Cr q1-3 months during induction (KDIGO 2021 GN)
- Steroid AE: glucose + BP + bone density + cataract + mood at each visit (KDIGO 2021 GN)
- CNI trough monitoring per agent (tacro 5-10 ng/mL; cyclo 100-150 ng/mL) (KDIGO 2021 GN)
- CBC + LFTs q1-2 weeks during CY; q1-3 months on MMF (KDIGO 2021 GN)
- BP at each visit, target <130/80 (KDIGO 2021 GN)
- Annual DEXA on long-term steroid (KDIGO 2021 GN)
- Relapse surveillance — urine dipstick at home; UPCR clinic q3-6 months in remission (KDIGO 2021 GN)

Setting (outpatient) monitoring:
- UPCR + serum albumin + eGFR q1-3 months on induction (KDIGO 2021 GN)
- CNI trough per agent (KDIGO 2021 GN)
- CBC + BMP + LFTs per agent (KDIGO 2021 GN)
- BP at each visit (KDIGO 2021 GN)
- DEXA q1-2 years on steroid (KDIGO 2021 GN)

Follow-up plan: Relapse counseling + bone protection (steroid exposure) + vaccinations (annual flu, COVID, PCV20) + steroid-sparing planning if SD/FR + post-transplant recurrence counseling (KDIGO 2021 GN)
- Close-out criterion: Long-term plan documented (KDIGO 2021 GN)

Monitoring phase: UPCR + albumin + creatinine + steroid adverse effects (glucose, BP, bone, infection) + relapse surveillance at home (urine dipstick) (KDIGO 2021 GN)

Disposition

Current setting: outpatient — Primary management setting — induction → remission → relapse retreatment → SD/FR steroid-sparing → maintenance; q3-6 month nephrology visits; CV + bone + fertility long-term (KDIGO 2021 GN)

Disposition criteria:
- Continue outpatient q3-6 months if stable (KDIGO 2021 GN)
- Admit for severe nephrotic / VTE / SBP / AKI / infection (KDIGO 2021 GN)
- Transition to transplant clinic if approaching ESRD (KDIGO 2024 CKD)

Escalation triggers (move to higher acuity):
- Rising UPCR + falling albumin → relapse → reinitiate induction (KDIGO 2021 GN)
- No response to induction at 4 wk pediatric / 16 wk adult → re-biopsy for FSGS (KDIGO 2021 GN)
- New fever + neutropenia on immunosuppression → ED (KDIGO 2021 GN)
- CKD progression toward ESRD → transplant evaluation; route neph.ckd.core.v1 (KDIGO 2024 CKD)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Adult-onset idiopathic MCD — biopsy mandatory; slower response to steroid (4-16 wk for first remission) (KDIGO 2021 GN; Korbet)
- [SEVERE] Paraneoplastic MCD — Hodgkin lymphoma association; B symptoms + adenopathy + LDH; renal often improves with lymphoma treatment (KDIGO 2021 GN)
- [SEVERE] Steroid-dependent (relapse on or within 2 wk of taper) OR frequently relapsing (≥2 in 6 mo / ≥4 in 12 mo) — escalate to CNI / CY / rituximab / MMF (KDIGO 2021 GN; Hodson Cochrane)

Citations

- KDIGO 2021 Glomerular Diseases + Cochrane corticosteroid therapy for childhood nephrotic syndrome (2015) + KDIGO 2024 CKD [PMID:34556256](https://pubmed.ncbi.nlm.nih.gov/34556256/)
- Cited evidence (PMID 25785660) [PMID:25785660](https://pubmed.ncbi.nlm.nih.gov/25785660/)
- Cited evidence (PMID 38490803) [PMID:38490803](https://pubmed.ncbi.nlm.nih.gov/38490803/)

Last reconciled with current guidelines: 2026-05-22.
References
  • KDIGO 2021 Glomerular Diseases + Cochrane corticosteroid therapy for childhood nephrotic syndrome (2015) + KDIGO 2024 CKD — PMID:34556256
  • Cited evidence (PMID 25785660) — PMID:25785660
  • Cited evidence (PMID 38490803) — PMID:38490803