Sir, A type 1 adult diabetic patient without previous microalbuminuria suffered from the explosive onset of nephrotic syndrome, with all the laboratory and histopathologic features of idiopathic minimal change disease (MCD). Co-administration of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) led to complete remission within 2 weeks. This case illustrates the efficacy of a first-line treatment with Angiotensin II (Ang II) antagonists on a background that would have lead to steroid untoward effects if this conventional approach had been chosen. It suggests that Ang II antagonists might be beneficial to other patients with MCD and avoid corticosteroid treatment. A 32-year-old man was hospitalized for the sudden onset of oedema. He had been diagnosed with type 1 diabetes at the age of 21 and was treated with insulin. One year before his serum creatinine level was 72 μmol/L and he had no albuminuria. He was 167 cm tall and weighed 80.4 kg. Blood pressure was 142/80 mmHg. He had pitting oedema of the lower extremities and pleural effusions. Funduscopy was normal, and a vibration test was only slightly disturbed. Urinalysis revealed 3+ protein with no erythrocytes or casts. Laboratory data found a serum creatinine of 81 μmol/L; total protein, 40 g/L; serum albumin, 17 g/L; 24-h urinary protein, 10.6 g; haemoglobin A1c, 6.8%. Antinuclear antibodies, antineutrophil cytoplasmic antibodies, antistreptolysin O and complement fractions were all within normal limits. The urinary protein selectivity index was 0.03. The renal biopsy examined by light microscopy yielded 9, slightly hypertrophic, nonsclerotic glomeruli with mild mesangial expansion without nodule formation. The glomerular basement membrane (GBM) thickness was normal. A small area of tubular atrophy was observed. There were no mononuclear cells in the interstitium. Arteries and arterioles showed no sclerosis or hyalinosis. Immunofluorescence disclosed linear IgG staining of the GBM and of the tubular basement membranes (TBM). Electron microscopy disclosed diffuse podocyte foot process fusion. The mesangial areas displayed a mild increase in matrix and no dense deposits. The TBMs were thicker than normal. A diagnosis of MCD was considered as most probable, occurring by coincidence in a diabetic with no definitive diabetic glomerulopathy. In an attempt to avoid glucocorticoid treatment, he was commenced on lisinopril 10 mg and losartan potassium 50 mg. Blood pressure was normalized, urinary protein started to decrease rapidly and was nil on day 16 (Figure (Figure11). Fig. 1 Clinical course of the patient. This graph illustrates the rapid remission of nephrotic syndrome following treatment with Ang II antagonists. Cases of MCD occurring in diabetics have been described [1] and complete remission was obtained in them with corticosteroid or immunosuppressive treatment. However, despite the well-known antiproteinuric effect of Ang II antagonists [2–6], in none of these cases was a similar treatment undertaken alone. We feel that in our patient Ang II antagonists were credited with an unexpected success and avoided the toxic effects of corticosteroids and/or of immunosuppressive medications. We admit that a spontaneous remission cannot be ruled out, as it has been observed in up to one-third of adults with MCD [7,8]. However, in such a case it is slowly obtained and requires a mean time of 79 weeks [7]. This leads to believe that Ang II antagonists were the best explanation for the rapid remission in our patient. This case prompts us to suggest that Ang II antagonists should be systematically tried in MCD and that corticosteroids might be avoided with this symptomatic first line treatment, a treatment that has the advantage of being devoid of major side effects. Conflict of interest statement. None declared.
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Apr 18, 2014
A Begum + 3
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